Understanding and Dealing with

Trauma and Abuse

An Educational Group











Kristina Muenzenmaier, MD Donald E. Sampson, PhD, CRC, NCC
Lisa J Norelli, MD Katherine Ann Alexander, RN, MS

Barbara Stephens, RN, MS Heather Huckeba, CSW
Understanding and Dealing with
Trauma and Abuse






An Educational Group






Kristina Muenzenmaier, MD Donald E. Sampson, PhD, CRC, NCC
Lisa J Norelli, MD Katherine Ann Alexander, RN, MS

Barbara Stephens, RN, MS Heather Huckeba, CSW






























New York State Office of Mental Health
Trauma Initiative Publication
1998, Revised March 2014

ACKNOWLEDGMENTS


The authors wish to give special thanks to the group participants at Queens Village Outpatient
Clinic, Creedmoor Psychiatric Center, Queens Village, New York. As participants in our groups,
they were instrumental in helping in the refinement of the content of this manual. As survivors, they
were our teachers, helping us to better understand how childhood sexual abuse influences them on
an ongoing basis. We also thank the Bronx and Creedmoor Psychiatric Centers for their support in
allowing staff members to participate actively in the development of this manual. J anet G Benton,
PsyD was instrumental in the final completion of the manual. Without her help and commitment, we
would probably still be working on the manuscript. Thanks to Laurie Caro for the use on the front
cover of her original painting entitled Despair, which so aptly captures the subject of this manual.
Thanks, Laurie friend, artist, survivor. The authors also wish to thank J anet Chassman, Trauma
Coordinator, New York State Office of Mental Health, for her support and encouragement of not
only this work, but for her endeavors over the years addressing the issues of persons with histories
of sexual abuse and serious mental illness.



























This project was supported by the Trauma Initiative, Training Bureau,
New York State Office of Mental Health


Copyright 1998 by Kristina Muenzenmaier and Donald E. Sampson
Revised with permission 2014 by Lisa J Norelli, J ohn OConnor, Vukasin Milenkovic

UNDERSTANDING AND DEALING WITH TRAUMA AND ABUSE:
AN EDUCATIONAL GROUP

TABLE OF CONTENTS



INTRODUCTION i-v

An Educational Approach i
Background ii
Revision Notes (2014) iv

THE EDUCATIONAL GROUP MODEL iv-v

Development of the Model iv
General Guidelines and Group Structure iv

SPECIAL CONSIDERATIONS FOR GROUP LEADERS v-viii

Screening and Selecting Group Members v
Safety vi
Educational and Therapeutic Roles vi
Contracting vii
Co-Leader Issues vii
Supervisory Issues viii

USING THE MANUAL viii-ix

REFERENCES x-xii

THE SESSIONS 1-54


Session 1: Contracting and Orientation to the Group 1
Session 2: Staying Safe Within and Outside the Group 6
Session 3: What is Abuse? 10
Session 4: Talking and Learning about Abuse 17
Session 5: Protecting Your Safety: Should You Disclose? 21
Session 6: Reactions of Others to Disclosure about Abuse 25
Session 7: Effects of Abuse on the Individual 30
Session 8: Experiencing PTSD and Dissociation 35
Session 9: Coping as a Child and as an Adult: Safety Issues 40
Session 10: Controlling Trauma-Related Experiences 43
Session 11: Support and Resources: Avoiding Re-victimization 48
Session 12: Wrap Up 52




APPENDICES 56-66

Appendix A:
Group Evaluation Form 56
Trauma Group Screening Instrument 57
Adverse Childhood Experiences Scale 59
Trauma Pre- Group Questionnaire 60

Appendix B:
Thoughts for the Day 61

Appendix C:
Suggested Reading 63






UNDERSTANDING AND DEALING WITH TRAUMA AND ABUSE
AN EDUCATIONAL GROUP


INTRODUCTION
AN EDUCATIONAL APPROACH
In recent years the long-term effects of childhood abuse and neglect have increasingly been found to
compound difficulties already experienced by people diagnosed with severe mental illness (SMI).
There is often increased interference in cognitive and affective functioning, increased stigmatization
and shame, and increased social isolation among people in this population. Despite these findings,
people diagnosed with SMI are often not assessed or treated for trauma and abuse. Even if a person
is known to have a history of abuse, the trauma is often not treated because of concern that
symptoms of the mental illness will be exacerbated. Not addressing traumatic history at all, however,
may place patients at continuing risk for repeating cycles of decompensation, substance abuse, non-
suicidal self-injury (NSSI), and other symptomatology. Childhood adversity has been associated
with premature mortality, and higher rates of physical health problems, mental health problems, and
health risk behaviors in adulthood. (Felitti VJ , et al, 1998; Edwards VJ et al, 2003; Dube SR et al,
2005)
During the early '90s, while providing treatment services at the Queens Village Outpatient Clinic,
one of the authors, Kristina Muenzenmaier, conducted a research study in which female outpatients
were interviewed about sexual abuse, physical abuse, and neglect histories. The Queens Village
clinic is an outpatient department of the Creedmoor Psychiatric Center, a New York State
Psychiatric facility. The women interviewed had diagnoses of schizophrenia, affective disorders,
usually with psychotic features, and/or schizoaffective disorder, as well as various Axis II
(personality) Disorders.

Muenzenmaier and colleagues found that 65% of the sample of females interviewed had a history of
childhood abuse or neglect, with 45% having been sexually abused, 51% physically abused, and
22% neglected. Only 32% of the sexually abused and 20% of the physically abused women,
however, were identified as such by their therapists (Muenzenmaier, Meyer, Stuening, & Ferber,
1993).

Finding little published research and limited group protocols for treatment, Muenzenmaier and co-
authors Donald Sampson, Kathy Alexander, Lisa Norelli, Heather Huckeba, and Barbara Stephens,
subsequently developed and implemented educationally oriented, sexual abuse trauma groups for
women who had been diagnosed with SMI. The treatment strategy was developed over the course of
five years at the Queens Village clinic. The authors have worked for many years with people
diagnosed with SMI in both inpatient and outpatient settings.
The authors prepared this manual in order to make available to other clinicians the group treatment
protocol they used in addressing the specific needs of these women who had been both sexually



abused and diagnosed with SMI. The manual is conceived as an educational and problem-solving
tool. Its educational format is designed to help limit stimulation and anxiety and to provide a safe,
contained environment in which women diagnosed with SMI can begin working on trauma issues.

This manual outlines the structure and content of twelve, one-hour-sessions designed to help group
members gain an understanding of trauma and abuse, what symptoms they may experience as a result
of abuse, how they have managed their symptoms heretofore, and how they might manage them
differently in the future. The overarching intent of the approach is to teach the key principles of
trauma recovery, including personal empowerment, safety, and reconnection with others.

A guiding principle of the approach presented in this manual is that traumatized and abused people
can be empowered through education about the effects of childhood trauma. By gaining knowledge
and building skills, they can develop both inner strength and greater independence.

The authors view people who have experienced the double impact of mental illness and childhood
sexual abuse as survivors. They do not view them as pathological and/or passive victims. Rather,
survivors are people who have been able to cope with the effects of illness, abuse, and often neglect.
In addition, they have sustained the ability to maintain hope for better lives. The authors thus focus
on resiliency and ability to survive, not on deficiencies. Survivors are people in need of healing, not
fixing.

BACKGROUND
Reports of violence against women and children, and trauma-related alcohol and substance abuse,
have increased at an alarming rate over the past 15 years. In 1992, almost twice as many children
(1,261) were reported to have died of abuse and neglect compared to 685 children in 1985. During
the same time frame, reports of physical and sexual abuse increased to 2.9 million, a rise of 30%,
with 40% substantiated. Part of the increase was due to better reporting by doctors. Nearly one-half
of the children were under one year of age (New York Times, 1994).
In studies of female inpatients and outpatients diagnosed with SMI, rates of child hood sexual abuse
range from 20% to 54% (Beck & van der Kolk, 1987; Bryer, Nelson, & Miller, 1987; Carmen,
Reiker, & Mills, 1984; Cole, 1988; Craine, Henson, & Colliver, 1988; Herman,1986; J acobson,
1989; J acobson & Harold, 1990; J acobson & Richardson, 1987; Muenzenmaier et al., 1993; Rose,
Peabody & Stratigeas, 1991; Rosenfeld, 1979). Rates of either sexual abuse or physical abuse at
some point in their lives have been reported at 81% for female inpatients diagnosed with SMI
(J acobson & Richardson, 1987) and 65% (Muenzenmaier et al, 1993) and 68% for female
outpatients (J acobson, 1989). For additional information, see Alexander & Muenzenmaier, 1998.

Higher rates of psychiatric symptomatology have been found among women with SMI who have
also been sexually and/or physically abused. For instance, there are increased rates of depression,
psychosis, dissociation, flashbacks, self-destructive behaviors, including suicidal symptoms and
attempts, self-mutilation, alcohol and substance abuse, borderline personality disorder, and panic



attacks (Alexander & Muenzenmaier, 1998; Beck & van der Kolk, 1987; Briere & Zaidi, 1989;
Brown & Anderson, 1991; Bryer et al., 1987; Linehan, Armstrong, Suarez et al., 1991;
Muenzenmaier et al., 1993; Stein et al., 1996; Wagner & Linehan, 1994). For many abuse survivors,
psychiatric symptomatology is often caused by or coexists with trauma. Symptomatology may stem
from severe mental illness or trauma or often co-morbidly.

Muenzenmaier and colleagues' study (1993) notes that only 20% of the clients identified with
physical abuse and 32% with sexual abuse were reported as such by their therapists. Failure to
address abuse histories in people already diagnosed with SMI may lead to misdiagnosis, or incorrect
emphasis on certain aspects of diagnosis, with the consequence of serious treatment mistakes
(Alexander & Muenzemaier, 1998; Rosenberg, Drake & Mueser, 1996). For instance, antipsychotic
medications may be prescribed that actually reduce a person's ability to work on trauma-related
issues and may compound problems of dissociation or other symptoms of Post-Traumatic Stress
Disorder. Without careful assessment of the etiology of psychiatric symptoms, people may be at
greater risk for repeated cycles of decompensation and rehospitalization, which, in turn, heighten
their experiences of defeat and humiliation. Furthermore, institutional denial or minimization of
abuse can recreate and/or perpetuate some of the original abuse dynamics.

Patients themselves are often unwilling to disclose abuse histories because of shame, guilt, fear of
blame, and/or lack of sufficient trust. Sometimes people have made disclosures in the past only to
find that professionals were not interested in or sensitive to their abuse histories. Professional staff
are often not trained to take abuse histories at all, and when they do take them, they may fail to
believe the abuse occurred or they may blame the victims as being responsible for the abuse.
Professionals also may not sufficiently establish the rapport needed to elicit disclosure (Alexander,
1996; Alexander & Muenzenmaier, 1998; Muenzenmaier et al., 1993). Especially in the inpatient
setting, men and women may be disbelieved or reports of abuse are attributed to psychotic
symptoms. Professionals, fearing patient decompensation, have traditionally been encouraged to
avoid issues that may cause stress and consequent stimulation of psychotic or self-harming
symptoms.

Fortunately, assessment procedures are gradually beginning to change and several states have now
adopted intake interviews in psychiatric emergency rooms and psychiatric hospital admissions that
include questions about physical and sexual abuse and neglect (Alexander & Muenzenmaier, 1998).
The importance of treatment has also begun to gain recognition. In addition to individual
psychotherapy, time-limited, cognitive-behavioral and/or process-oriented group work has been
found to help participants overcome issues of shame, guilt, secrecy, stigmatization, and social
isolation among people not diagnosed with SMI (Alexander & Muenzenmaier, 1998; Alexander,
Neimeyer, Follette, Moore, & Harter, 1989; Brandt, 1989; Courtois, 1988; Follette, Alexander, &
Follette, 1991; Frank, Anderson, Stewart, Dancu, Hughes, & West, 1988; Hazzard, Rogers, &
Angert, 1993; Herman & Schatzow, 1984; Mennon & Meadow, 1992; Resick, J ordan, Girelli,



Hutter, & Marhoefer-Dvorak, 1988; van der Kolk, 1987). Women who have been diagnosed with
SMI, however, have traditionally been excluded from trauma groups because of perceived emotional
fragility, cognitive limitations, and/or behavior problems (Alexander & Muenzenmaier, 1998). In
order to provide treatment for this cohort, group models need to be developed that take these
difficulties into account.

2014 REVISION NOTES
Recognizing the largely unaddressed need for approaching trauma and childhood abuse in men with
SMI, Lisa J Norelli, J ohn OConnor, and Vukasin Milenkovic of the Capital District Psychiatric
Center (CDPC) have revised and updated the manual with the authors permission. Language was
modified to communicate the session topics in a more gender-neutral format. In addition, the topic
area has been broadened to include childhood adversity, as conceptualized in the Adverse
Childhood Experiences survey (ACE), and adult trauma and abuse. The ACE studies have shown
that childhood adversity and abuse is associated with significant negative social, health and
economic outcomes. (See www.acestudy.org/home) Finally resources were modified to the
localities served by CDPC and online resources were also included. We hope that incorporating
these changes will help facilitate discussion in both men and women with trauma histories.


THE EDUCATIONAL GROUP MODEL
Development of the Model
As discussed above, the educational approach presented in this manual was developed by the authors
in the Queens Village Outpatient Clinic. Participants attended pilot groups as part of their outpatient
treatment. All women in the group had been diagnosed with SMI. Survivors responded to an
announcement of the group or were referred by therapists. Group members participated in regularly
scheduled individual therapy sessions and psychiatric evaluations throughout the duration of the
group. This approach was also used in an abbreviated version of four sessions on an in-patient unit.
The model was adapted from the Workshop Model for Family Education, which was originally
designed to serve a higher-functioning population (Courtois, 1993).

General Guidelines and Group Structure
Similar to addiction recovery models, the educational model in this manual reflects the
understanding that trauma recovery has a long time frame, is a nonlinear process, and may involve
relapse. The model also reflects J udith Herman's three stages of healing, as discussed in her book
Trauma and Recovery (1992). The model focuses on Herman's first stage of recovery -- establishing
safety psychologically, physically, and socially -- and reiterates this theme in every session.
Whereas Herman's second stage involves "retelling the story" in a supportive environment, survivors
in the beginning education group addressed by this manual for people diagnosed as SMI are
encouraged to learn about trauma but are generally advised not to discuss too- personal material
within the group. Instead, it is critical that each group member meets regularly with an individual
therapist to process issues that come up in the group, including disclosure and working through



personal history. The authors of the manual wish to stress that the group model does not replace
individual psychotherapy. Group work is seen as adding to the work of individual therapy that is
essential for recovery from sexual abuse.
The third stage in Herman's model helps survivors, who often have become isolated as a result of
trauma, both to understand their own personal dynamics and to reconnect interpersonally. Although
not the focus of the educational model in this manual, some of these issues are addressed in the
sessions.
Treatment is built on the premise that clients will learn and use what they are ready to incorporate. It
is expected that some people will want or need to repeat the series of sessions. A primary goal is to
encourage participants to establish the locus of control for life within them, including their use of
treatment.
The sessions in the educational model are short (no more than one hour), the meetings are regular
(one time per week at the same hour), and the content is adapted to the cognitive capacity of group
members. The structure, although clearly delineated, is purposely flexible in order to serve the needs
of more disorganized and seriously ill group members. (See Using the Manual, below; also see
Stone, 1996.)

Group size should be based on the characteristics of members, with higher- functioning groups
typically being larger. Because co-leaders often need to monitor affect in the group, it is suggested
that group size be limited to six to eight participants, even when the group is composed of higher-
functioning individuals.

SPECIAL CONSIDERATIONS FOR GROUP LEADERS
Screening and Selecting Group Members
Assessment in a trauma group is an ongoing process that begins with an initial assessment to
determine an individual's appropriateness for the group. Potential group members will need to be
screened through an individual interview with the group leaders (see Appendixes A and B). It is
suggested that during the interview leaders give a brief overview of the group and inquire about an
individual's interest in participating, with the aim of assessing comfort level and motivation. As
noted above, it is extremely important that each member is being treated by an individual therapist.
Other important issues to address are safety, the client's relationship to her individual therapist,
ability to connect to others, and history of and/or continued substance and/or alcohol abuse, eating
disorders, self-mutilation, or other self-destructive behaviors, and other coping styles that might
interfere with progress in a group or with the progress of the group as a whole.

Although it is generally better if a participant is not actively abusing alcohol or drugs, substance
abuse is a coping mechanism used by many survivors. If addiction is not too severe, the group may
be useful and may help motivate entry into substance abuse treatment. Leaders will also need to



assess a persons current stage of recovery. It is very important to assess psychiatric
symptomatology such as acute paranoia, psychotic episodes, or severe depression. Such symptoms
may inhibit understanding and ability to tolerate stimulating content and thus limit participation in
the group.

The above are important areas of assessment but are not necessarily criteria for disqualification.
Individuals considered inappropriate for group work are those who cannot sit through even short
group sessions, who are disruptive or aggressive towards other group members, are actively
psychotic, or who are intoxicated.

If there is a large disparity in the range of functioning of prospective group members, then the group
leaders may want to consider making two groups or limiting the group to members at similar
functional levels. When group members are too disparate in level of functioning or fragility, leaders
tend to focus on those with the greatest needs in order both to maintain physical and emotional
safety and to communicate at a level that all group members will understand. Because this may leave
higher-functioning, more intact people frustrated, the authors suggest making group composition as
consistent as possible.

Safety
Special respect and attention need to be given to the issue of safety. In addition to guidelines set
forth in the first sessions, safety is emphasized and reiterated throughout the cycle of treatment. In
groups composed of clients not diagnosed with SMI, members may be encouraged to explore painful
memories and affect. In the educational model proposed in this manual, however, individuals who
are experiencing pain and/or anxiety should be counseled first to maintain their own safety by
"Saying No" until, and if, they feel comfortable exploring their feelings.

Similarly, withdrawal may be regarded as a coping mechanism rather than a hindering defense.
Clients who withdraw within the groups by, for instance, putting on headphones in the middle of a
session, or who physically withdraw by leaving the room, should not necessarily be confronted for
inappropriate behavior. Likewise, short-term dissociation should be viewed as a coping mechanism
used to protect a group member from psychological harm. In some cases, group leaders actually may
want to reinforce or encourage momentary withdrawal as a means of helping individuals to maintain
their own safety.

Educational and Therapeutic Roles
Leaders need to explain the differences between education and therapy and reinforce the importance
of maintaining an educational format. Leaders also need to be alert to group members' psychological
states and be comfortable with and able to shift quickly between educational and therapeutic
intervention roles. Although the purpose of the model presented in this manual is primarily



educational and group oriented, individual crises may arise that could take precedence over
educational goals.


Contracting
Because group members may forget and/or avoid sessions, especially when painful material is being
discussed, contracting about time issues is extremely important. Verbal contracting is considered to
be more effective than written contracting and needs to be reiterated on a regular basis, perhaps at
the beginning of each session. Co-leaders also need to be highly committed to establishing stability
and predictability by keeping a regular schedule, not missing sessions, and being on time. The
authors also suggest that groups not be started during heavy holiday or vacation seasons in order to
avoid interruptions. Contracting should regularly include safety as well as confidentiality, time, and
schedule issues.

Co-Leader Issues
The authors suggest that there always be two group leaders, and with a more fragile population, it is
suggested that both leaders be female (see below). An advantage of having two leaders is that one
can attend to emotional states of individuals in the group while the other attends to the group
content. A need may also arise where one co-leader must attend to a member outside of the group
itself while the other leader continues the session. If possible, once the crisis situation is resolved,
the co-leader should return to the group.

It is important, especially if co-leaders are individual therapists for any members of the group, to
separate educational from therapeutic roles and maintain an educational focus within group sessions.
Leaders who work individually with group members must be keenly aware of their possession of
private information and the importance of maintaining confidentiality in the group setting. Both
leaders should be continually alert to issues concerning safety, confidentiality, and trust.

Group leaders may or may not be childhood abuse survivors. Most important is that those who work
with trauma survivors need to be extraordinarily empathic and able to work in partnership with
clients. Because survivors have often been pathologized and blamed, approaches that empower and
foster independence need to be used.

Co-leaders should have a thorough understanding of Post-Traumatic Stress Disorder, Dissociative
Disorders, and Borderline Personality Disorder and their implications for childhood abuse survivors.
In addition, they must be aware of psychotic symptoms and how to handle them effectively. Because
many clients diagnosed with SMI will have experienced homelessness, abused alcohol or drugs,
used sex for survival, used self- mutilation to regulate affect, suffered stigmatization, and may be
passive and dependent, or, alternatively, be hostile and violent, it is important that staff members
working with this group be very aware of a variety of relevant mental health, survival, and coping
issues. Group leaders should also familiarize themselves with relevant trauma literature; including



survivors' stories (see Suggested Reading, Appendix D).

The issue of co-leader gender should be carefully considered. The general wisdom has been that
trauma groups for female survivors should have female co-leaders. However, the authors have
successfully conducted groups both with two female co-leaders and one female and one male co-
leader in outpatient groups of all-female and all-male trauma survivors. The authors' experiences
were positive using both co-leader models. When asked her opinion about mixed-gender co-leaders,
one female group member said "Most of my issues are with males. It might be helpful to have a male
leader."

A back-up leader should be prepared to substitute in the absence of one of the regular co-leaders.
Like co-leaders, the back-up should be trained in childhood trauma and recovery and mental illness.
It is helpful if the back-up is known to group members. Participation in screenings and the initial
session may be useful in integrating the back- up leader into the group. If back-up is not available,
the authors suggest cancelling a group rather than conducting it with only one leader. A second
leader is critically important in sharing teaching responsibilities, monitoring effects on participants,
handling emergencies, and/or checking on members who may leave the group temporarily due to
over-stimulation from group sessions. Cancellation is especially advised if the remaining leader is
male in a female group.

Supervisory Issues
Co-leaders of a survivors' group need to be supportive of each other and willing and able to process
their experiences after each session. They also should be involved in weekly supervision to explore
the strong countertransference, boundary, and splitting issues that are common in this kind of work.
In particular, leaders may feel overwhelmed by others' experiences of trauma and may experience
vicarious or secondary trauma as a result. Group leaders may also inadvertently revictimize members
by minimizing or blaming. Leaders of survivor groups may also struggle with rescue and control
issues. In the same way that clients meet with individual therapists outside the group to work
through survivor issues, co-leaders must use supervision to process what is very often extremely
emotionally disturbing material and to maintain a clear clinical focus.


USING THE MANUAL
The manual consists of protocols for twelve group sessions. Each session in the manual describes
the Objective of the Session, a Presentation Outline, Recommendations for Group Leaders, the
Thought for the Day, and Materials needed for the session. Handouts have been prepared on separate
pages for easy copying.

An important component of each session is the "Thought for the Day." It is used to conclude the
session as well as begin the following one, thus providing a focus for trauma-related cognitions and
continuity between sessions. Templates of the 12 thoughts are provided in Appendix C. In their



sessions with group members, the authors reproduced the thoughts on blank business cards available
at office supply stores. Group members reported that these easy-to-carry "Thought for the Day"
cards were valuable adjuncts to session content.

One session involves the use of a video of survivors telling their stories. The tape used by the
authors was from an Oprah Winfrey special, but other high-quality and appropriate videos could be
used. Because this type of presentation can be particularly powerful, it is recommended that group
leaders carefully screen a tape for evocativeness of content. Leaders also should choose tapes about
people to whom particular survivor populations can relate in order to avoid rejection of material as
irrelevant.

Group leaders are encouraged to use the manual flexibly while at the same time maintaining the
basic structure that will ensure safety within and across sessions. Some sessions in the manual may
require two or more actual meetings in order to cover the material. In addition to the sessions,
Appendices A and B have been included to help leaders choose group members. Appendix C is a
collection of the Thoughts for the Day from the sessions and Appendix D is a list of suggested
reading materials.







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400.

Rosenfeld A. (1979). Incidence of a history of incest among 18 female psychiatric patients.
American J ournal of Psychiatry, 136:791-795.

Stein M, Walker J , Anderson G, et al. (1996). Childhood physical and sexual abuse in patients with
anxiety disorders and in a community sample. American J ournal of Psychiatry, 153:275-277.

Stone W. (1996). Group psychotherapy for people with chronic mental illness.
New York: Guilford.

van der Kolk B. (1987). Psychological trauma. Washington, DC: American Psychiatric Press.

Wagner A & Linehan M. (1994). Relationship between childhood sexual abuse and topography of
parasuicide among women with borderline personality disorder. J ournal of Personality
Disorders, 8:1-9.












Group Sessions
Session 1
1

Session 1

Contracting and Orientation to the Group

Objectives

To establish a working contract and group goals.

Presentation Outline

Introduce yourselves as co-leaders and state why you want to be involved in the group (based on
careful self-examination) to set a tone of interest, caring, and safety.

"Check in" to determine each member's personal sense of safety and comfort.

Present the basic philosophy and educational model of the group.

Trauma work is often neglected or overlooked in the general population and is particularly so with
people who are diagnosed with mental illness. Many people who have survived abuse often have had
their experiences go unrecognized, minimalized, denied, or disbelieved. Many consumers in the
mental health system have to overcome the double stigma of mental illness and trauma or abuse.

Survivors should have the opportunity to learn about trauma and abuse and understand its effects on
both childhood and adulthood. The group is an educational rather than a therapeutic model. The
purpose is to learn about trauma and abuse rather than to talk about members' own abuse experiences.
Going around the group, ask participants to introduce themselves and say as little or as much as they
choose about themselves and what they would like to gain from being a member of the group. (Note:
Group leaders will need to closely monitor self- disclosure and redirect to a general focus on trauma.)

Present the Individual and Educational Goals of the Group.

Individual Goals
Short Term

How one uses the thought for the week
Develop one's own resource list

Long Term

Become aware of one's own triggers and symptoms
Understand many symptoms as coping mechanisms
Improve support system and social relationships
Improve intimate relationships
Session 1
2

Educational Goals

Staying safe within and outside the group
What is trauma and abuse?
Talking and learning about trauma and abuse
Protecting your safety: Should you disclose?
Reactions of others to disclosure of trauma or abuse
Effects of trauma and abuse on the individual
Learning about Post Traumatic Stress Disorder and dissociation
Coping as a child and as an adult: safety issues
Controlling trauma-related experiences
Avoiding re-victimization

Check-in with group members again to determine that they feel personally safe and are comfortable
continuing.

Distribute the Session 1 Handout and discuss the Contract (Structure and Expectations for Group
Participants and Co-Leaders) and the Flow of the Sessions.

Contract & Structure

The series of group sessions is scheduled to meet weekly for twelve weeks.
Sessions will be 45 minutes long.
Sessions will deal with trauma and/or abuse using an educational model.
Participants are expected to attend each session and to be on time.
Following completion of the 12 sessions, members may be offered the opportunity to continue
their trauma work in additional sessions. These may again be educational or may be more skills
focused.

Expectations for Group Participants and Co-Leaders
Confidentiality must be respected.
Do not talk about other members or their issues outside of the group.
If issues arise that need to be discussed with the primary therapist, the group member will be
encouraged to do so, or the co-leaders will seek permission to do so on the member's behalf.
To ensure safety, in instances where there is a perceived danger to self or others, confidentiality
will not be maintained.
Participants are encouraged to let group leaders know if any problems arise as a result of the
group sessions.
In order to maintain and teach recognition of personal safety boundaries, co-leaders need to
assure participants that they will not pressure a member to reveal personal experiences or push a
member beyond their comfort level. Group members should be encouraged to set their own limits
and to respect the limits needed by others in the group.
Session 1
3

Flow of the Sessions

Checking-in with group members to determine each person's sense of safety and comfort
Follow-up on the previous session's Thought for the Day
Identification of the topic of the day
Brief presentation and discussion of content
Distribution of the Handout and the Thought for the Day

Checking-out at the end of the session with group members to determine each person's sense of
safety and comfort

Clarify questions about the handout material.

Distribute the Thought for the Day and discuss the implications for work both inside and outside the
group.

Check-in with members. Be sure each member feels safe enough to leave the session.

Recommendations to Group Leaders

During the first session be particularly aware of setting a proper tone: Group participants need to feel
safe and empowered, not stigmatized or revictimized. An important prerequisite to establishing the
tone will be the understanding both by leaders and members that participation in the educational
group should be voluntary. Group members should not feel that group participation is overtly or
covertly mandatory as a treatment requirement.

By the end of the first session, be sure that the survivor perspective has already started to be
conveyed.

Establish the educational model by focusing on content and gently steering participants away from
excessive self-disclosure. Encourage group members to think why learning about abuse can
contribute towards their healing. This issue will be discussed in the following group.
Use simple and clear language in communicating with group members.

Be aware of individual reactions as indicators of discomfort that need attention for future sessions,
e.g., a member dissociating or leaving the group and not returning.

Encourage a member to stay in the group if he/she starts to leave, but do not force anyone to remain
if he/she is too uncomfortable. Leaders need to remember that a member's choice to leave may be
empowering and therapeutic. Also, the individual may not be ready to address childhood trauma
issues at this time. Try to encourage the person to talk about the reason/discomfort, instead of just
Session 1
4

leaving the group or failing to return for the next session. If the client does leave and/or does not
return, this statement of "No" should be addressed in individual sessions with the group leaders or
individual therapist. If a person does need to leave, it is very important that a co-leader checks with
the person to be sure he/she is safe.

Make a point of not singling out any individual in the group to talk about their issues. Invite all
members to participate verbally, but do not insist. Many members will be keenly aware of the content
of the discussion, despite their seeming lack of participation.

Respect silence. Often intense work is done during silence.


Thought for the Day

Learning about abuse is a step toward healing.


Materials

Thought for the Day Cards
Session 1 Handout (Contract and the Flow of Sessions)


Session 1
5

Session 1 Handout
Group Contract and Expectations


The series of group sessions is scheduled to meet weekly for twelve weeks.
Sessions will be 45 minutes long.
Sessions will deal with trauma and abuse using an educational model.
Participants are expected to attend each session and to be on time.
Following completion of the 12 sessions, members may be offered the opportunity to
continue their trauma work in additional sessions. These may again be educational or may
be more skills focused.

Expectations for Group Participants and Co-Leaders

Confidentiality must be respected.
Do not talk about other group members or their issues outside of the group.
If issues arise that need to be discussed with the primary therapist, the group member will
be encouraged to do so, or permission will be sought for the co-leaders to do so in the
member's behalf.
To ensure safety, in instances where there is a perceived danger to self or others,
confidentiality will not be maintained.
Participants are encouraged to let group leaders know if any problems arise as a result of
the group sessions.
In order to maintain and teach recognition of personal safety boundaries, leaders will not
pressure a member to reveal personal experiences or push a member beyond their comfort
level. Group members are encouraged to set their own limits and respect the limits needed
by others in the group.

Flow of the Sessions

Checking-in with members to determine each person's sense of safety and comfort
Follow-up on the previous session's Thought for the Day
Identification of the topic of the day
Brief presentation and discussion of content
Distribution of the Handout and the Thought for the Day.
Checking-in at the end of the session with group members to determine each person's
sense of safety and comfort
Session 2
6

Session 2
Staying Safe inside and outside the group

Objective

To outline personal safety issues for group members both within and outside the group.

Presentation Outline

Check-in with group members to insure that their feelings of personal safety and comfort are
adequate for today's group work. Identify any special situations or issues relating to the previous
session that need attention.

Use the check-in as a bridge to last session's Thought for the Day:
Learning about trauma and abuse is a step toward healing.

Discuss participants' reactions to this thought and if/how they considered the thought during the
week. Identify any special situations or issues relating to the previous week's session that need
attention.

Trauma from abuse and neglect can be a difficult topic to discuss and is likely to temporarily
increase stress. Part of today's focus is staying safe within the group, which is of paramount
importance. Over the long run, the group is designed to be helpful, not harmful, to members. The
other focus is staying safe outside the group to avoid re-victimization. Following are some of the
reasons why it is important to think carefully about safety.
For some survivors of trauma or abuse, it is difficult to fully take their own safety into consideration.

Trauma survivors may:

Believe they do not have the right to keep themselves safe.
Believe they lack the power to keep themselves safe.
Have trouble asserting or speaking up when they do not feel safe.
Not understand safe boundaries.
Have trouble controlling temper or anger.
Place themselves in unsafe situations; or,

Within the group a member may:

Dissociate or just "fade away" during a discussion of abuse that brings up painful memories.
Experience anger at another group member or co-leader as issues are being discussed.
Get up and leave the group for the session, or for good.

Session 2
7

Outside the group a survivor may:

Go along with a potentially harmful suggestion at the urging of another, sometimes against the
survivor's better judgment.
Use drugs, alcohol or engage in other high-risk behavior.
Walk or drive alone late at night, or go to isolated locations.
Being alone with a person or persons he/she does not trust.
Continue to be involved with persons who abused them as a child, or stay with an unsafe or abusive
person as an adult.
Feel they cannot control a situation so avoids going to a place that is actually safe.
On the other hand, avoid situations that are actually safe, but feared.

Distribute the Session 2 Handout for review and discussion.

Keeping Safe Within the Group

Learn to recognize and listen to your own personal signs of stress/anxiety/fear.
It is OK to say "no" within the group if you do not wish to talk.
There will not be pressure to reveal personal experiences, unless you feel comfortable doing so.
No one has to stay within the group if she feels uncomfortable; however, members are asked to
try to let the group know if something is uncomfortable in order to allow the group to respond to
individuals' needs.

Keeping Safe Outside the Group

Know who you can trust.
Share information about your trauma or abuse history or illness only with those you can trust.
Develop a support system of people you can trust.
Know helpful resources.
Always be aware of your environment and keep yourself safe.

Leaders should point out that many of the suggestions for keeping safe are the same regardless of the
environment. The important first step in keeping safe is for each member to trust their own
awareness of unsafe situations. Members need to learn to better identify their "gut" feelings and to
use them to keep themselves away from harm.

Group leaders should ask group members if they have trouble staying safe and encourage them to
give examples.

Ask members if there are situations they can anticipate during the next week that they feel may be
unsafe and discuss how safety can be maintained.
Session 2
8

Part of being safe is feeling comfortable enough to talk about one's trauma or abuse history. Ask
group members if they feel comfortable discussing issues related to their trauma with their primary
therapists. Because having someone safe to discuss trauma issues with is of utmost importance in
healing, effective communication with individual therapists needs to be in place or to be established
for all group members.

Hand out the Thought for the Day and encourage group members to keep themselves safe during
the following week. The thought will be discussed at the beginning of the next session.

Ask members how they felt about today's group.
Was it helpful?
Did people feel that their experiences were supported by the group?

Check-in with members to see if they are comfortable with their level of personal safety and comfort
at this time.

Recommendations for Group Leaders

Within the group, establishing a safe tone and environment is essential and will need ongoing
attention throughout the sessions. Group leaders should understand that due to breach of boundaries
and trust as children, the issue of safety is paramount for abuse survivors. Safety in the group is
necessary for members to be able to stay connected to the group process.

In discussing guidelines for safety within and outside the group, co-leaders need to set a tone that
supports empowerment and permission to listen to and respond to the participants individual needs
and set their own boundaries, while also being willing to ask for help when needed.

Discussion should not focus on personal trauma or abuse experiences, but should reflect session
content for the day. Leaders should redirect personal abuse-related issues to the primary therapist for
individual work in therapy. Because it is also important for group co-leaders to learn how to stay
safe within the group, supervision needs to be in place by this second session.

Thought for the Day

You deserve to feel and be safe!


Materials
Thought for the Day Cards
Session 2 Handout (Keeping Safe Within the Group and Keeping Safe Outside the Group)
Session 2
9

Session 2 Handout

Keeping Safe in the Group

Learn to recognize and listen to your own personal signs of stress/anxiety/fear.
It is OK to say "no" within the group if you do not wish to talk.
There is no pressure to reveal personal experiences unless you feel comfortable doing so.
No one has to stay within the group if he/she feels uncomfortable; however, members are
asked to let the group know if something is uncomfortable in order to allow the group to
respond to individuals' needs.


Keeping Safe Outside the Group

Know who you can trust.
Only share information about your trauma history, abuse history or illness if you want to and
only with those you can trust.
Develop a support system of people you can trust.
Know helpful resources.
Always be aware of your environment and keep yourself safe.
Session 3
10


Session 3
:
What is Trauma and Abuse?

Objectives

To define different types of trauma, abuse and neglect.
To identify how common trauma and abuse is and to discuss myths and
misunderstandings about trauma and abuse.

Presentation Outline

Check-in with group members to ensure their feelings of personal safety and comfort are
adequate for today's group work. Identify any special situations or issues relating to the previous
session that need attention.

Use comments of group members to lead into last session's Thought for the Day:
You deserve to feel and be safe!

Review the Session 3 Handout. Leaders should convey to the group members that childhood
maltreatment can take many forms and includes neglect and emotional, physical, and sexual
abuse of children under the age of 18. All these forms of abuse can have a great impact on how a
person feels and acts, both as a child and as an adult.

Definition of terms

Neglect is the failure, when resources are available, to provide a child with the basic care needed
to survive and grow. Neglect is to be distinguished from the failure to provide care because of
poverty, a distinction that is sometimes difficult to make.

Examples of neglect include:
Depriving a child of food, clothing, or shelter.
Locking a child out of the house and refusing to let him/her in.
Not providing general medical care, e.g., vaccinations, eye wear, dental care.
Failing to supervise a child who is playing out of doors, in the streets, or at home.
Not ensuring a child attends school.

Abuse involves inflicting harm with the risk of long-term effects.
Abuse can be defined as:

Emotional abuse: Using words to belittle or berate, or failure to give positive signs of caring,
which may lead to emotional distress.

Session 3
11

Examples of emotional abuse include:
Calling a child names, such as faggot, queer, fat, ugly.
Telling a child he/she is dumb, useless, or stupid and will never amount to anything.
Telling a child he/she is worthless and should never have been born.
Depriving a child of love or using love to control a child's behavior.
Using a position of power over a child to inflict harm.
Threats to or witnessing the abuse of someone close to the child.
Threats to or witnessing the abuse or serious harm to a pet.

Physical abuse: Hitting, striking, or otherwise harming a child in such a way as to create risk of
physical damage that may have long-term effects.

Examples of physical abuse include:
Leaving marks on the body of a child, e.g., bruises, cuts.
Beating a child with a broomstick, electrical cord, or other implement.
Hitting a child.
Pulling hair, kicking, or throwing a child.
Holding a child by the shoulders and shaking violently back and forth.
Seriously injuring a child, e.g., breaking bones, twisting limbs, damaging joints.
Denying the child medical care for a serious injury.
Witnessing physical abuse to person close to the child.
Being made to watch the physical abuse to a pet.

Sexual abuse: Contact or non-contact sexual use of a child. This form of abuse may involve
sexual touching, forcing a child to touch an adult in a sexual way, encouraging inappropriate
sexual contact with another child or adult, taking sexually oriented pictures, and so forth.
Incest is defined as sexual abuse that occurs within the family between persons related by blood,
marriage, adoption, stepfamily relationships, or a live-in relationship involving persons within
the household.

Examples of sexual abuse include:
Touching a child's genitals for the purpose of sexual excitement.
Forcing two children to perform sexual acts. e.g. rub or touch each other's genitals
Taking nude photographs or videos of a child.
Making a child watch pornography.
Engaging in oral, anal, or vaginal sex with a child.
Inserting objects into the childs body (e.g. vagina, anus, mouth, penis) for the purpose of
sexual excitement.
Fondling a child.
Making a child perform oral sexual acts.
Session 3
12

Making a child engage in sexual acts with animals.
Being made to witness or participate in the sexual abuse of another child or person.
Drug or alcohol facilitated sexual abuse.

Myths about Childhood Abuse
Many myths exist regarding childhood trauma and abuse, some of which are listed below.
Discuss how such beliefs, when held by the child or significant others, may impact upon the
individual:

The child caused the abuse to happen.
The child seduced the adult.
The child acted or looked provocative.
The child deserved the abuse because he/she was bad or stupid, etc.
The child really wanted the abuse to occur.
Unless there was actual physical contact, there was no abuse.
Unless there was sexual penetration, there was no abuse.
Unless the penis penetrated the vagina, there was no abuse.
Unless there was physical force, there was no abuse.
Unless it hurt, there was no abuse.
It is not abuse to be exposed to adults having sex.
The child could have stopped the abuse if she or he had tried hard enough.
Abuse happens in most if not all families.
If the child felt pleasure, it was not abuse.
If the abuse felt warm and loving, the child must have been encouraging it.
Only men are abusers.
If a woman abuses a boy, its not really abuse because she is teaching him about sex.
All abusers are strangers.
Abuse only happens in poor families.

Although survivors of abuse may end up believing some myths or fearing that they may be true,
leaders need to remind group members that trauma and abuse is never the fault of the child.
Other issues related to trauma and abuse not included in the Session 3 Handout should be
addressed in group discussion where appropriate, e.g.:
Peer exploratory behavior among children of similar ages is generally not considered to be
abusive. The beliefs and feelings of each child involved are the determining factors in whether, or
how much, harm results from exploratory behavior.

Perpetrators often use differences in power to groom and then physically or sexually exploit a
child. They also may have other psychopathological reasons for exploitation, e.g., misguided
feelings of anger, inadequacy, jealousy, envy, and voyeurism.
Session 3
13

Contact sexual abuse includes touching, rubbing, insertion of objects, vaginal or anal penetration,
oral contact, etc. There may be great differences in the effect of abuse on the individual, both as a
child and as an adult.

Some factors that impact upon the effects of trauma or abuse include:

Age of the child at the time of the abuse
Duration of the abusive experience
Use of threats, seduction, and/or physical force
Relationship between the perpetrator and child
If abuse is continuing or episodic
If abuse is familial or non-familial
If abuse is conducted by a single or multiple perpetrators
Supports available to the child
Coping abilities of the child

How common is trauma & abuse during childhood? AT LEAST:

One half of children have experienced physical assault.
One in four girls has been sexually abused.
One in ten boys has been sexually abused.
One in eight children has been neglected.
One third of children witness violence or victimization of others.
Many children experience more than one type of trauma or abuse, and they are at higher risk
for abuse as adults.

Sexual abuse in the general population studies has a prevalence rate of 25%, whereas the rate
among inpatient and outpatient psychiatric patients is around 40% to 70%, almost twice the rate
found in the general population. Sexual abuse may begin at very early ages, with it not being
uncommon in children under the age of 5. It may occur only once, or may be ongoing, lasting for
many years. Average age of onset is 8; average duration of years is 4. Physical force may or may
not be used. Children may be seduced, bribed, and verbally coerced into abusive relationships.

Remember that, from a treatment (rather than a legal) perspective, it is the individual's personal
experience that determines whether or not a particular situation was abusive for him or her. Also,
psychological and physical preparedness rather than chronological age is often more important in
the impact of an abusive situation on a child.

Distribute the Thought for the Day and briefly discuss its meaning with participants.

Session 3
14

Ask members how they felt about today's group.
Was it helpful?
Did people feel that their experiences were supported by the group?

Check-in to see if all members are comfortable with their level of personal safety and comfort at
this time.

Recommendations for Group Leaders
Although the purpose of this particular group session is to educate members about neglect and abuse
issues, leaders should remember that the experience of the members during the session is more
important than the specifics of prevalence rates, legal definitions, etc. Material provided for this
session may be too comprehensive for one meeting and can be presented over two or more sessions.
(Note time availability and involvement of group members in making this determination.) Also,
leaders may wish to select pertinent information and examples that are appropriate for their
participants.

Group members may want to talk or ask about their own experiences with neglect and/or abuse. As
noted previously, leaders should monitor and control disclosure carefully and be sure that members
are also discussing issues with primary therapists. Leaders will need to exercise clinical judgment in
allowing some individual expression while still maintaining the primary, educational focus of the
group.

Thought for the Day

Trauma and abuse is very common.


Materials

Thought for the Day Cards
Session 3 Handout (Definition of Terms and Myths about Abuse)
Session 3
15

Session 3 Handout
Definition of Terms

Neglect is the failure, when resources are available, to provide a child with the basic care needed to
survive and grow. Neglect is to be distinguished from the failure to provide care because of poverty, a
distinction that is sometimes difficult to make.
Examples of neglect include:
Depriving a child of food, clothing, or shelter.
Locking a child out of the house and refusing to let him/her in.
Not providing general medical care, e.g., vaccinations, eye wear, dental care.
Failing to supervise a child who is playing out of doors, in the streets, or at home.
Not ensuring a child attends school.

Abuse involves inflicting harm with the risk of long-term effects. Abuse can be defined as:

Emotional abuse: Using words or actions to belittle or berate, or failure to give positive signs of caring,
which may lead to emotional distress.
Examples of emotional abuse include:
Calling a child names, such as faggot, queer, fat, ugly.
Telling a child she is dumb, useless, or stupid and will never amount to anything.
Telling a child she is worthless and should never have been born.
Depriving a child of love or using love to control a child's behavior.
Using a position of power over a child to inflict harm.
Witnessing the abuse of a person close to the child.
Being forced to watch abuse or harm to an animal or pet.

Physical abuse: Hitting, striking, or otherwise harming a child in such a way as to create risk of
physical damage that may have long-term effects.

Examples of physical abuse include:
Leaving marks on the body of a child, e.g., bruises, cuts.
Beating a child with a broomstick, electrical cord, or other implement.
Hitting or punching a child.
Pulling hair, kicking, or throwing a child.
Holding a child by the shoulders and shaking her violently back and forth.
Seriously injuring a child, e.g., breaking bones, twisting limbs, damaging joints.
Denying the child medical care for serious injury.



Session 3
16

Session 3 Handout (continued)
Sexual abuse: Contact or non-contact sexual use of a child. This form of abuse may involve sexual
touching, forcing a child to touch an adult in a sexual way, encouraging inappropriate sexual contact with
another child or adult, taking sexually oriented pictures, and so forth.
Incest is defined as sexual abuse that occurs within the family between persons related by blood,
marriage, adoption, stepfamily relationships, or a live-in relationship involving persons within the
household.
Examples of sexual abuse include:
Touching a child's genitals for the purpose of sexual excitement.
Forcing two children to perform sexual acts. e.g. rub or touch each other's genitals
Taking nude photographs or videos of a child.
Making a child watch pornography.
Engaging in oral, anal, or vaginal sex with a child.
Inserting objects into the childs body (e.g. vagina, anus, mouth, penis) for the
purpose of sexual excitement.
Fondling a child.
Making a child perform oral sexual acts.
Making a child engage in sexual acts with animals.
Being made to witness the sexual abuse of another child or person.
Drug or alcohol facilitated sexual abuse

Myths about Abuse
Many myths exist regarding trauma and abuse. Some of these myths are listed below. Discuss how
such beliefs, when held by the child or significant others, may impact upon the individual:
The child caused the abuse to happen.
The child seduced the adult.
The child acted or looked provocative.
The child deserved the abuse.
The child really wanted the abuse to occur.
Unless there was actual physical contact, there was no abuse.
Unless there was sexual penetration, there was no abuse.
Unless the penis penetrated the vagina, there was no abuse.
Unless there was physical force, there was no abuse.
Unless it hurt, there was no abuse.
It is not abuse to be exposed to adults having sex.
The child could have stopped the abuse if she or he had tried hard enough.
Abuse happens in most if not all families.
If the child felt pleasure, she was not abused.
If the abuse felt warm and loving, the child must have been encouraging it.
Only men are abusers.
If a woman abuses a boy, it is not really abuse because she is just teaching him about sex.
All abusers are strangers.
Abuse only happens in poor families
Session 4
17

Session 4
Talking and Learning about Trauma and Abuse

Objective

To encourage participants to state the importance of talking about trauma and abuse.

Presentation Outline

Check-in with group members to ensure that their feelings of personal safety and comfort are
adequate for today's group work. Identify any special situations or issues relating to the previous
session that need attention.

Use comments of group members as a lead into last session's Thought for the Day:
Trauma and abuse is very common.

Ask members if they have seen someone sharing their trauma or abuse experiences on television talk
shows or documentaries. What were their reactions to these shows?

Show selected segments from a video presentation of adults talking about their childhood abuse
experiences. After the presentation, encourage group members to share their thoughts and feelings
about the video. The following questions can help guide the discussion.

Why would these people share their abuse experiences on television?
How do you think the people felt as they shared their experiences?
Did you believe that the abuse really happened?
What were your thoughts regarding their feelings of guilt, blame, and shame?
Did these people try to disclose the abuse while they were still children? How was it received?
What impact do you think it has for a child who cannot disclose to keep such a secret and to grow
up with it?
Why might a child keep a secret about her abuse experience?
Did the people on the video say how long after the abuse they first shared their experience with
another person? With whom did they share it? What was the person's reaction?
What other thoughts or reactions did members have?

Discuss with group members that many factors can influence the decision whether or not to talk,
including:

Private feelings: Self-blame, embarrassment, shameand/or guilt about the abuse experience; fear of
not being believed, fear of threats to the individual or their loved ones from the perpetrator.


Session 4
18

Threats to family unity and personal future:
Fear for the safety of family based on the perpetrator's threats.
Fear about what may happen to the perpetrator, and/or fear of family breakup and placement in foster
care.

Religious influences: Beliefs such as the importance of forgiveness, not wanting to harm others,
including a perpetrator, following the Golden Rule, and/or that God, not man, is to judge, can
influence a survivor's decision about disclosure.

Cultural and social factors: Some cultures are more accepting of disclosure than others. Some
may be very punitive and blame the victim. Societal attitudes affect the quality and level of support
that survivors can expect to receive.

Distribute the Thought for the Day and discuss its meaning with participants.

Ask members how they felt about today's group.
Was it helpful?
Did people feel that their experiences were supported by the group?

Check-in to see if all members are comfortable with their level of personal safety and comfort at this
time.

Recommendations for Group Leaders

The authors suggest that only the least dramatic and detailed segments from the video be presented in
this session. The vividness of persons discussing their abuse histories and their emotional distress
may be very intense, painful, and may serve as triggers for some group members. Survivors are
usually impacted strongly by the revelations of other survivors, especially if experiences are similar
to their own. Be particularly attentive during this session to symptoms of stress that group members
are likely to experience, e.g., anger, anxiety, dissociative responses, acting out.
Leaders should also note that there have been positive changes in the social acceptability to disclose
and discuss sexual abuse. Today in American society, there is more acceptance of disclosure and
more public discussion about trauma and abuse than in the past. It is common to see, hear, and read in
the media about abuse. Until fairly recently, trauma and abuse would not have been addressed in these
forums because it was not considered an "acceptable" topic for discussion.

Ask members how they felt about today's group.

Was it helpful?
Did people feel that their experiences were supported by the group?

Session 4
19

Check-in to see if all members are comfortable with their level of personal safety and comfort at this
time.

Thought for the Day

Talking about abuse can lead to healing.


Materials

Thought for the Day Cards
Segments from a video tape of adults talking about their childhood abuse experiences.
Session 4 Handout (Reasons Why People Might Keep Trauma/Abuse a Secret)
Session 4
20

Session 4 Handout

Reasons Why People Might Keep Trauma/Abuse a Secret

Many factors can influence the decision whether or not to talk, including:

Private feelings and threats toward individual or loved ones:
Self-blame, embarrassment, shame, and/or guilt about the abuse experience.
Fear of not being believed
Fear of threats from the perpetrator.


Threat to family unity and personal future:
Fear for the safety of family based on the perpetrator's threats.
Fear about what may happen to the perpetrator.
Fear of family breakup and placement in foster care.


Religious influences:
Beliefs such as the importance of forgiveness, not wanting to harm others, including a
perpetrator, following the Golden Rule, and/or that God, not man, is to judge, can influence a
survivor's decision about disclosure.


Cultural and social factors:
Some cultures are more accepting of disclosure than others. Some may be very punitive and
blame the victim. Societal attitudes affect the quality and level of support that survivors can expect
to receive.
There also have been positive changes in the social acceptability to disclose and discuss trauma
and abuse. Today in American society, there is more acceptance of disclosure and more public
discussion about trauma and abuse than in the past. It is common to see, hear, and read in the media
about abuse. Until fairly recently, abuse would not have been addressed in these forums because
abuse was not considered an "acceptable" topic for discussion.
Session 5
21

Session 5
Protecting Your Safety: Should you disclose?
Objectives

To encourage participants to recognize issues which are important when identifying people with
whom to discuss trauma or abuse experiences.

Presentation Outline

Check-in with each group member to ensure that feelings of personal safety and comfort are adequate
for today's group work. Identify any special situations or issues relating to the previous session that
need attention.

Discuss group members' reactions to and thoughts about last session's Thought for the Day:
Talking about trauma and abuse can lead to healing.

Introduce today's topic: Safety issues about deciding who to tell about one's abuse experience.
Emphasize the reality that some people are safe to talk with about abuse and others are not. Keeping
safe includes protecting oneself from those who will react negatively to knowledge of one's trauma or
abuse history. Each survivor needs to identify how they know they are safe when discussing trauma or
abuse with another person.

Reactions others have to hearing about trauma and abuse can help determine whether the survivor is
safe in disclosing.

Ask group members what kinds of reactions from another would be helpful to someone who tells of
their abuse. Members should be encouraged to especially look for non-blaming and non-judgmental
traits in the listener, as well as warmth and helpfulness.

Identify actual or feared reactions of others that might influence a person's decision to disclose. For
instance, telling of the trauma or abuse may lead to a continuation or even an escalation of the abuse.
Leaders should emphasize that talking with someone about trauma or abuse who will react negatively
or non-helpfully may lead to feelings of disempowerment or to re-victimization.

Identify with group members other reasons why some people do not feel and perhaps should not feel
safe disclosing. Unfortunately, because of these concerns, some people either wait a very long time
before disclosing or never disclose. Survivors need to discriminate what concerns are relevant when
considering disclosure.


Session 5
22

Potential Reasons for non-disclosure in Adulthood

Fear of disclosure as a child may continue into adulthood
Past disclosure leading to no action or to more abuse
Belief that the abuse was a survivor's own fault
Protecting a non-offending parent or other family member
Protecting the perpetrator
Fear of being punished
Fear of not being believed
Feelings of shame or guilt

Note that some people, instead of being afraid to talk about their histories, disclose indiscriminately --
everything with everybody. Discuss with group members how such indiscriminate disclosure can
lead to re-victimization.

Distribute and discuss the Session 5 Handout

Some Things to Consider if you are deciding whether or not to discuss abuse i ssues
Do you feel comfortable with the person?
Do you feel intimidated by or afraid of the person?
Does something inside tell you that you do not like or trust the person?
How long have you known the person?
Has the person ever hurt you before?
Will the person maintain confidentiality? If someone discusses things with you that he/she should
not, then you can be pretty sure the person will do the same with your information.
Do others trust the person?
First, be sure you trust the person and remember trust develops over time.
Test the person's reactions by talking about abuse in general before talking about your own.
Decide in advance whether or not you want to reveal abuse information.
Decide in advance how much you feel safe to disclose.
Go slowly.
If in doubt, do not share.

Distribute the Thought for the Day and briefly discuss its meaning with participants.

Ask members how they felt about today's group.
Was it helpful?
Did people feel that the group supported their experiences?

Check-in with each individual to see if all members are comfortable with their level of personal safety
and comfort at this time.
Session 5
23

Recommendations for Group Leaders

Be particularly attentive to reactions to last week's video segments. Participants are likely to have
been strongly affected by the presentation and follow-up is important. Some group members may
miss the session after the video presentation.

A reminder from last week: Discussions about disclosure either to family members or to people
outside of the family may be particularly stressful for group members.

Thought for the Day

It is important to know whom you can trust.


Materials

Thought for the Day Card
Session 5 Handout (Some Things to Consider If You are Deciding Whether or Not to Discuss
Abuse Issues)
Session 5
24

Session 5 Handout

Some things to consider if you are thinking about disclosing your trauma/abuse to someone

Do you feel comfortable with the person?

Do you feel intimidated by or afraid of the person?

Does something inside tell you that you do not like the person?

How long have you known the person?

Has the person ever hurt you before?

Will the person maintain confidentiality? If someone discusses things with you that he/she should
not, then you can be pretty sure the person will do the same with your information.

Do others trust the person?

First, be sure you trust the person and remember trust develops over time.

Test the person's reactions by talking about abuse in general before talking about your own.

Decide in advance whether or not you want to reveal abuse information.

Decide in advance how much you feel safe to disclose.

Go slowly.

If in doubt, do not share.










Session 6
25

Session 6
Reactions of Others to Trauma and Abuse Disclosures

Objective

To help participants identify at least one possible positive and one possible negative reaction
to disclosure of abuse.

Presentation Outline

Check-in with group members to ensure that their feelings of personal safety and comfort are
adequate for group work. Identify any special situations or unfinished issues relating to the previous
session that need attention.

Discuss participants' thoughts over the past week on last session's Thought for the Day:
It is important to know whom you can trust.

Some people think that sharing about abuse is therapeutic. Do you think it is helpful for someone
who has been sexually abused to share abuse experiences with others?

How did the others react to the stories of sexual abuse in the video shown two sessions ago?

In our culture society's views often make it difficult to discuss histories of abuse. For this reason and
those given below, it may be easier and wiser for some people to talk about abuse experiences with
someone other than a family member. For other people, however, the reverse may be true. Why do
group members think there might be differences?

Various factors influence how people may receive disclosure about trauma or abuse. Some of these
include:
Whether the person believes you or not
Your relationship with the person to whom you are disclosing
The person's relationship with the abuser
Whether the abuse was experienced previously or is ongoing
If the abuse happened once or continued over time or is still continuing
Whether the abuser was a family member or was outside the family
The possibility of the perpetrator being violent towards the person you are telling

Special concerns may be present when disclosing to a family member, including:
The relative power within the family of the perpetrator and the person with whom you are
discussing your abuse
Session 6
26

The family composition, e.g., single-parent household or intact family
Family rules regarding the place and role of a child relative to adults
Family styles of handling stressful situations
Cultural views relative to abuse
Degree of dependence of the family upon the perpetrator
Choices between the needs of a child and the needs of the family

Possible implications for the family:
Loss of the home
Loss of income
Loss of a parent, spouse, lover, or other family member
Loss of respect within the community if the abuse becomes know

Legal implications:
The child may be removed from home and placed in foster care.
The perpetrator may be prosecuted and sent to prison.
There may be a long and stressful court fight.
Painful testimony about specific details of the abuse may be required.

Special concerns about health professionals:
Therapists' attitudes about abuse
Attitudes about abuse of mental health staff in clinics, emergency rooms, and hospitals
Attitudes of hospital staff about restraints, injections, use of quiet rooms

Distribute the Session 6 Handout for review and discussion.

Possible Reactions to Disclosure of Abuse
The reaction to your disclosure, whether or not the disclosure is made to a family member, may be
positive and helpful:
Listening to you
Believing you
Understanding your feelings about the abuse
Intervening to stop the abuse
Showing concern for your well being
Protecting you physically and emotionally
Taking your concerns and experiences seriously
Empowering and strengthening you
Not judging you
Assuring you that you are not alone with your secret
Taking your feelings and welfare seriously
Session 6
27


The reaction may be negative or hurtful, again, whether or not the disclosure is within the family:
Not believing you
Blaming you for what happened
Avoiding you after the disclosure
Changing the subject or refusing to discuss it
Saying you must never tell anyone else about it
Telling you this happens to everyone and that you should just forget it
Rejecting or avoiding you
Showing anger toward you for your disclosure
Physically harming you for revealing the information
Being horrified at your disclosure
Verbally attacking you for disclosing
J udging or thinking less of you
Saying you are lying or making up the story
Saying you are exaggerating
Blackmailing you with the information
Downplaying or minimizing your experiences or saying it was not really so bad
Doing nothing following your disclosure
Telling you the family will break up and that you will be placed in foster care
Threatening to put the abuser in jail
Shaming you
Re-victimizing you by actions or words

Ask members how they felt about today's group.
Was it helpful?
Did people feel that the group supported their experiences?

Check-in with each participant to see if all members are comfortable with their level of personal
safety and comfort at this time.

Group Leader Recommendations

Although the list of possible negative reactions to disclosure is longer, it is important during this
session to balance the discussion between positive and negative as much as possible.
Group leaders may want to ask group members how they have reacted to others' disclosures of abuse,
inside or outside the group. How did members feel about the people who disclosed on the video?
Discussions about disclosure, either with family members or with people outside the family, may be
particularly stressful for group members. Also, some participants may already be working on issues
regarding disclosure and the discussion may greatly increase their stress levels.

Session 6
28

Thought for the Day

The child is not responsible for the trauma or abuse.


Materials

Thought for the Day Cards
Session 6 Handout (Possible Reactions to Abuse)
Session 6
29

Session 6 Handout
Possible Reactions to Disclosure of Abuse


Positive Reactions

Listening to you
Believing you
Understanding your feelings about the abuse
Intervening to stop the abuse
Showing concern for your well being
Protecting you physically and emotionally
Taking your concerns and experiences
seriously
Empowering and strengthening you
Not judging you
Assuring you that you are not alone with your
secret
Taking your feelings and welfare seriously















Negative Reactions

Not believing you
Blaming you for what happened
Avoiding you after the disclosure
Changing the subject or refusing to discuss it
Saying you must never tell anyone else about it
Telling you this happens to everyone and that
you should just forget it
Rejecting or avoiding you
Showing anger toward you and your disclosure
Physically harming you for revealing the
information
Being horrified at your disclosure
Verbally attacking you for disclosing
J udging or thinking less of you
Saying you are lying or making up the story
Saying you are exaggerating
Blackmailing you with the information
Downplaying or minimizing your experiences
or saying it was not really so bad
Doing nothing following your disclosure
Telling you the family will break
up and that you will be placed in foster care
Threatening to put the abuser in jail
Shaming you
Re-victimizing you by actions or words










Session 7
30

Session 7
Possible Effects and Reactions to Trauma and Abuse
Objective

To help group members state the connection between their abuse histories and current
thoughts, feelings, and behaviors.

Presentation Outline

Check-in with group members to insure that their feelings of personal safety and comfort are
adequate for group work. Identify any special situations or unfinished issues relating to the previous
session that need attention.

Use comments of group members to lead into last session's Thought for the Day:
The child is not responsible for the abuse.

Distribute the Session 7 Handout. The authors suggest that you limit today's group discussion to three
or four topics under each category. Group members will probably spontaneously address many of the
other effects and reactions in subsequent sessions.

Possible Effects of and Reactions to Trauma and Abuse

Physical Effects
Physical injuries: scars, bruises, broken bones, etc.
Long-term effects on genital, urinary and/or GI systems
Long-term health effects (e.g. heart disease, asthma, hypertension)
Gastrointestinal disorders
Eating disorders: anorexia, bulimia, and obesity often resulting from distortions of body
image
Somatization: tightness of throat, pressure on chest, difficulty breathing, chronic pain
Loss of voice, speechlessness
Body memories

Emotional/Psychological Reactions

Shame and guilt
Anger or difficulty controlling anger (explosive or inhibited anger)
Lowered self esteem
Disturbed image of self and/or body
Denial
Session 7
31

Sleep and dream disturbances
Feeling of loss of control
Depression
Anxiety
Passivity
Outrage
Irritability
Substance and alcohol abuse
Self-harm and/or suicidal ideation
Concentration problems, school or work difficulties

Loss of a Sense of Meaning in Life

Loss of sustaining faith, beliefs, and/or values
Over-investment in faith, beliefs, and/or values
Sense of hopelessness
Sense of helplessness
Diminished interest in activities
Lack of initiative or motivation
Feeling very different from others, even feeling non-human or alien

Impact of Relationships with Others

Isolation/withdrawal
Difficulties forming and maintaining attachments and relationships
Difficulties with trust
Repeated search for a rescuer (may alternate with isolation and withdrawal)
Overly seductive behavior
Compulsive promiscuity
Inhibited sexuality and/or loss of sexuality (may alternate with promiscuity)
Difficulty determining and establishing safety with others
Failure to protect oneself from re-victimization
Engaging in abusive relationships

Alterations in Views towards the Perpetrator

Preoccupying feeling and thoughts about the perpetrator
Contradictory feelings and thoughts about the perpetrator (e.g., love versus hate)
Sense of having a special relationship with the perpetrator
Acceptance of the abusive belief system of the perpetrator
Session 7
32


Ask members how they felt about today's group
Was it helpful?
Did people feel that their experiences were supported by the group?

Check-out to see if all members are comfortable with their level of personal safety and comfort at this
time.

Group Leader Recommendations

When asking participants for their feedback, leaders should be prepared for members to bring up
specific and individual issues such as suicidal gestures, self-injurious behavior, etc. Be sure to leave
enough time to adequately discuss these with individuals and with the group.

Group leaders should emphasize that many "effects" of abuse are actually a person's way of coping or
dealing with abuse in order to survive. When understood this way, many of a person's "problems" or
"symptoms" make sense.

The focus of this session should be to reframe "symptoms" as "coping mechanisms." People should
be recognized and honored for what they have done to survive rather than stigmatized and shamed.

Group leaders should note that coping mechanisms can be understood and validated without
condoning those ways of coping that are no longer useful. For instance, substance abuse may have
been used to cope with and survive overwhelming feelings, but a client would still be encouraged and
supported to now find a safer coping mechanism, i.e., one that is not potentially harmful.

Thought for the Day

Trauma and abuse can lead to emotional and physical difficulties.


Materials

Thought of the Day Cards
Session 7 Handout (Possible Effects of and Reactions to Trauma and Abuse)
Session 7
33

Session 7 Handout
Possible Effect of and Reactions to Trauma and Abuse


Physical Effects

Physical injuries: scars, bruises, broken bones, etc.
Long-term effects on genital, urinary, and/or GI system
Long-term health effects (e.g. heart disease, asthma, hypertension)
Gastrointestinal disorders
Eating disorders: anorexia, bulimia, and obesity
Somatization: tightness of throat, pressure on chest, difficulty breathing, chronic pain
Loss of voice, speechlessness
Body memories

Emotional/Psychological Reactions

Shame and guilt
Anger or difficulty controlling anger (explosive or inhibited anger)
Lowered self esteem
Disturbed image of self and/or body
Denial
Sleep and dream disturbances
Feeling of loss of control
Depression
Anxiety
Passivity
Outrage
Irritability
Substance and alcohol abuse
Self-harm and/or suicidal ideation
Concentration problems, school or work difficulties

Loss of a Sense of Meaning in Life
Loss of sustaining faith, beliefs, and/or values
Over-investment in faith, beliefs, and/or values
Sense of hopelessness
Sense of helplessness
Diminished interest in activities
Lack of initiative or motivation
Feeling very different from others, even feeling non-human or alien
Session 7
34

Session 7 handout (continued)

Impact of Relationships with Others

Isolation/withdrawal
Difficulties forming and maintaining attachments and relationships
Difficulties with trust
Repeated search for a rescuer (may alternate with isolation and withdrawal)
Overly seductive behavior
Compulsive promiscuity
Inhibited sexuality and/or loss of sexuality (may alternate with promiscuity)
Determining and establishing safety with others
Failure to protect from re-victimization
Engaging in abusive relationships

Alterations in Views towards the Perpetrator

Preoccupying feelings and thoughts about the perpetrator
Contradictory feelings and thoughts about the perpetrator (e.g., love versus hate)
Sense of having a special relationship with the perpetrator
Acceptance of the abusive belief system of the perpetrator
Session 8
35



Session 8
Experiencing Post-Traumatic Stress Disorder (PTSD) and Dissociation

Objective

To help group members be able to identify at least one characteristic of Post-Traumatic Stress
Disorder (PTSD) and Dissociation.

Presentation Outline

Check-in with group members to insure that their feelings of personal safety and comfort are
adequate for group work. Identify any special situations or unfinished issues relating to the previous
session that need attention.

Use comments of group members to lead into last session's Thought for the Day:
Trauma and abuse can lead to emotional and physical difficulties

People who have experienced severe trauma and/or repeated trauma, especially during childhood
often develop PTSD and dissociative symptoms. Discuss the following descriptions of PTSD,
Dissociative Disorders, and the related disorders of Complex PTSD and Borderline Personality
Disorder.

PTSD
As described by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), "the essential
feature of PTSD is the development of characteristic symptoms following exposure to an extreme
traumatic stressor. . . "
The stressor may be the actual or threatened death or serious injury to the self, witnessing such an
event happening to others, and or learning about such an event happening to family members or close
associates.
One characteristic symptom of PTSD is persistent re-experiencing of the event through recollections,
reliving, dreams, physiological responses, and/ or dissociative experiences. Other symptoms include
persistent avoidance of activities, people, and/or places associated with the event, persistent numbing
of thoughts, feelings, and general responsiveness, and persistently heightened arousal, as
demonstrated by hyper-vigilance or exaggerated startle response. Symptoms must occur for more
than one month and must cause significant distress and impairment to a person's functioning.

Dissociative Disorders
Dissociative experiences refer to the disruption of consciousness, memory, identity, or perception of
the environment, functions that are usually integrated.
Session 8
36

People who have experienced trauma may develop Dissociative Identity Disorder, the primary
symptom of which is the presence of two or more distinct identities or personality states within the
same person.
In Depersonalization Disorder people experience themselves as detached from their minds and/or
bodies as if they were outside observers of themselves.
Some people develop Dissociative Amnesia, in which the traumatic event is forgotten, or enter into a
Dissociative Fugue, in which whole parts of one's life are forgotten, after they have experienced
trauma

Complex PTSD and Borderline Personality Disorder
In her book Trauma and Recovery (1992), J udith Herman proposed the term Complex Post Traumatic
Stress Disorder to describe symptoms of people who have been exposed to totalitarian control for
prolonged periods of time. Such totalitarian systems can include long-term sexual and physical abuse
within the family (page 121).
Herman and others also have suggested that prolonged abuse from a very young age is commonly
associated with the diagnosis of Borderline Personality Disorder (BPD). Characteristics of BPD
include pervasive instability in maintaining interpersonal relationships, monitoring self-image, and
regulating affects. People with BPD also tend to exhibit highly impulsive behaviors.

Distribute the Session 8 Handout for discussion.

Common Experiences of Survivors of Childhood Trauma and Abuse

Difficulties Regulating Feelings and Behavior
Reactions to triggers or situations reminiscent of the original trauma; experiencing
dissociation, somatization, etc. when exposed to certain situations or triggers
Numbing, not feeling anything at all, or greatly diminished feelings in situations where one
would normally experience strong feelings
Inability to identify or label feelings; not knowing what to call feelings you are having
Restricted range of emotions; lack of highs and/or lows people normally experience
Avoidance of activities related to the trauma; intentionally staying clear of reminders
Flashbacks; intrusive memories with experiences as vivid as the original trauma; it is like
being there all over again
Distressing dreams about the event; dreams intrude in sleep often or occasionally and are
generally very disturbing
Difficulty concentrating; easily distracted, space out, or lose contact with what is going on
around oneself for a period of time; others may not be aware of this
Hyper-vigilance; jumpy, startling easily when surprised or immediately startling wide awake
when aroused from sleep
Eating difficulties; anorexia, bulimia, overeating, or obesity
Session 8
37

Sleep difficulties; falling or staying asleep, or sleeping a great deal
Strong changes in mood or affect with little apparent cause
Explosive or inhibited anger (may alternate)

Problems with Consciousness and Perceptions
Intrusive memories; reliving traumatic events through intrusive memories and feelings
Not being fully "present" in reality; spacing out, losing time (dissociation)
Thoughts and feelings are disjointed and do not seem to connect (dissociation)
You, others, or things around you do not seem real or are distorted; such as alterations in size,
appearance, movement, texture, color, etc. (derealization and depersonalization)
Having two or more distinct identities or personality states (Dissociative Identity Disorder;
formerly Multiple Personality Disorder)
Feeling what is happening to your mind or body is not happening to you (Depersonalization
Disorder)

Amnesia about the traumatic event(s) or about whole phases or years of one's life; may not remember
elements of the event or longer time periods (Dissociative Amnesia or Dissociative Fugue)

Survivors may also have other psychiatric difficulties (co-morbidity), in addition to reactions to their
childhood trauma, and exhibit symptoms that include delusions and hallucinations. Although these
may be true symptoms of a different psychiatric disorder (e.g., as in schizophrenia), they may be
memories and flashbacks that are incorrectly interpreted.

Distribute the Thought for the Day and briefly discuss its meaning with participants.

Ask members how they felt about today's group
Was it helpful?
Did people feel that their experiences were supported by the group?

Check-out to see if all members are comfortable with their level of personal safety and comfort at this
time.

Group Leader Recommendations

Group members often learn a great deal from this session that they have not been taught before (or do
not recall). The session can greatly clarify their personal experiences and may need to be continued in
the next session. Referrals to primary therapists may especially be needed after this session (these
sessions).


Session 8
38

Thought for the Day

People have individual reactions to childhood trauma and abuse

Materials
Thought of the Day Cards
Session 8 Handout (Common Experiences of Survivors of Childhood Trauma and Abuse)
Trauma and Recovery by J udith Herman (1992) is also an excellent resource.
Session 8
39


Session 8 Handout

Common Experiences of Survivors of Childhood Trauma and Abuse

Difficulties Regulating Feelings and Behavior
Reactions to triggers or situations reminiscent of the original trauma; experiencing
dissociation, somatization, etc. when exposed to certain situations
Numbing, not feeling anything at all, or greatly diminished feelings in situations where one
would normally experience strong feelings
Inability to identify or label feelings; not knowing what to call feelings you are having
Restricted range of emotions; lack of highs and/or lows people normally experience
Avoidance of activities related to the trauma; intentionally staying clear of reminders
Flashbacks; intrusive memories with experiences as vivid as the original trauma; it is like
being there all over again
Distressing dreams about the event; dreams intrude in sleep often or occasionally and are
generally very disturbing
Difficulty concentrating; easily distracted, space out, or lose contact with what is going on
around oneself for a period of time; others may not be aware of this
Unexplained loss of time, finding yourself in a place with no memory of how you got there,
finding items you have no memory of purchasing
Hyper-vigilance; jumpy, startling easily when surprised or immediately startling wide awake
when aroused from sleep
Eating difficulties; anorexia, bulimia, overeating, or obesity
Sleep difficulties; falling or staying asleep, or sleeping a great deal, nightmares
Strong changes in mood or affect with little apparent cause
Explosive or inhibited anger (may alternate)

Problems with Consciousness and Perceptions
Intrusive memories; reliving traumatic events through intrusive memories and feelings
Not being fully "present" in reality; spacing out, losing time (dissociation)
Thoughts and feelings are disjointed and do not seem to connect (dissociation)
You, others, or things around you are not real or are distorted; such as alterations in size,
appearance, movement, texture, color, etc. (derealization and depresonalization)
Having two or more distinct identities or personality states (Dissociative Identity Disorder;
formerly Multiple Personality Disorder)
Feeling what is happening to your mind or body is not happening to you (Depersonalization
Disorder)
Amnesia about the traumatic event(s) or about whole phases or years of one's life; may not
remember elements of the event or longer time periods (Dissociative Amnesia or Dissociative
Fugue)
Session 9
40


Session 9
Coping as a Child and as an Adult: Safety Issues

Objective

To help group members identify coping strategies used by abuse survivors.

Presentation Outline
Check-in with group members to insure that their feelings of personal safety and comfort are
adequate for group work. Identify any special situations or unfinished issues relating to the previous
session that need attention.

Use comments of group members to lead into last session's Thought for the Day:
People have individual reactions to childhood trauma and abuse.

It is important to remember that in order to cope; one must take care of one's physical self. People
tend to have more difficulty if they are not eating well or have not had sufficient rest.

Trauma and abuse survivors often continue to use coping strategies in adulthood that were useful to
them as children even though these strategies are no longer appropriate or helpful. This continued use
of inappropriate coping strategies is often one of the effects of abuse. Such strategies may, in fact, be
viewed as symptoms of the abuse.

For example, a child may hide in a closet, dissociate, or run away to avoid an abusive situation but
these behaviors may not be useful for adults. Even though inappropriate in adulthood, an effective
childhood coping strategy often becomes a style for dealing with stressful situations. People are more
vulnerable during times of illness or stress or when they lack sleep.

Negative ways of coping with abuse may include such things as minimizing, forgetting, or denying
the abuse, drugs and alcohol, avoidance, spacing out, and overeating. A child may have copied
strategies from other family members who were either being abused themselves or witnessing abuse.

Successful coping may include identifying the memories of abuse while, at the same time, keeping
the memories and the feelings they will elicit under control. Thus, identifying ways of maintaining a
sense of safety and control becomes important in developing new coping strategies.

Group members should be encouraged to find support groups or supportive individuals, especially if
family and friends are not as helpful as members would like. Members may find it useful to meet
regularly with individuals whom they have identified as helpful.
Session 9
41


After first identifying old, ineffective strategies, members will need to actively think about and
implement new, effective ones for protecting themselves from further abuse or re-victimization. What
works for one person may not work for another. Each individual needs to identify or develop
strategies that work for them.

In later sessions the group will focus on strategies for coping with trauma after-effects.

Distribute the Thought for the Day and briefly discuss its meaning with participants.

Ask members how they felt about today's group

Was it helpful?
Did people feel that their experiences were supported by the group?

Check-out to see if all members are comfortable with their level of personal safety and comfort at this
time.

Group Leader Recommendations
Group members may need help locating appropriate support groups as well as individuals with whom
they can speak. Co-leaders should try to provide information about local resources (in addition to
those given in the Session 9 Handout) and should be prepared to discuss members' choices as part of
Session 11, Support and Resources: Avoiding Re-victimization.

Thought for the Day

Coping strategies needed by a child may not be useful to an adult

Materials

Thought of the Day Cards
Session 9 Handout (Some Local and State Resources)
Session 9
42

Session 9 Handout

Personal, Local, and State Resources

My Personal Resources
Therapists number:
Psychiatrists number:
Clinic or other treatment providers number:
Other Trusted Personal Supports or Resources:

NY State Resources
United Way Northeast NY region: Call 211 Monday through Friday 9AM to 5 PM
Free confidential information and referral on issues concerning food, housing, child care,
employment, health care, senior care, substance abuse, mental health, financial problems, crisis
counseling, legal matters, volunteer opportunities, etc.

New York State Coalition Against Sexual Assault, Albany, NY 518-482-4222
New York State Office for the Prevention of Domestic Violence 1-800-942-6906

Local Resources
CDPC Crisis 518-549-6500
Call 1-800-942-9606 to be directed to your local domestic violence resources
(Albany County) Equinox Domestic Violence Services (518) 432-7865
(Rensselaer County) Unity House of Troy (518) 272-2370
(Saratoga County) Mechanicville Area Community Service Center Domestic Violence Advocacy
Program(518) 664-4008
(Saratoga County) Domestic Violence and Rape Crisis Services of Saratoga County (518) 584-8188
(Schenectady County) YWCA of Schenectady (518) 374-3386
(Schoharie County) Catholic Charities of Schoharie County Crime Victims Program(518) 234-2231
(Warren, Washington, Saratoga) Catholic Charities The Domestic Violence Project (518) 793-9496

Online Resources/National Resources
Rape, Abuse, Incest National Network (RAINN) 1-800-656-HOPE www.rainn.org
After Silence www.aftersilence.org online information and support forums for men and women who
have experienced sexual assault, abuse, or violence.
Befrienders Worldwide www.befrienders.org online hotline referral and support to prevent suicide
PsychCentral www.psychcentral.com online support, education, resources for mental health
American Foundation for Suicide Prevention www.afsp.org resources, support 1-888-333-2377
National Suicide Prevention Lifeline 1-800-273-8255

Session 10
43

Session 10
Controlling Trauma-Related Experiences

Objective

To help group members identify at least one positive coping strategy for handling trauma-
related experiences.

Presentation Outline
Check-in with group members to insure that their feelings of personal safety and comfort are
adequate for group work. Identify any special situations or unfinished issues relating to the previous
session that need attention.

Remind participants that there are only two sessions left after today. What are participants' feelings
about the group's termination? If additional sessions are an option, discuss this with the group.

Use comments of group members to lead into last session's Thought for the Day:
Strategies needed by a child may not be useful to an adult.

Members need to know in advance what they should do when they encounter uncomfortable, abuse-
related experiences. Remind members that selecting strategies needs to be done in quiet, relaxed
moments, not when actually in a trauma-related situation or when under other stress. Following is a
list of strategies that have worked for other survivors to control unwanted body sensations,
dissociation, and flashbacks or intrusive memories.

Coping Strategies for Trauma-Related Experiences
Flashbacks can be very intrusive and disturbing, but you can learn to control their rate and intensity.
Floods of memories can be especially painful and should be controlled to the degree possible. Some
strategies that have been used successfully include relaxation training, thought stopping, distraction
techniques, and engaging in social activities with safe people. Remember that therapy is a safe place
to explore memories and their meaning.

Carry "safe items" with you. Find things that feel right to you, that ground you and give you
comfort. Some people use special stones, squishy rubber balls, crystals, small books, tiny toys, or
small puzzle games. An item should be something that soothes and that you can always carry with
you. Some people make a safety sack or use a box to contain their safe items. You can make it from
a small piece of cloth and piece of string, place your personal safe items in it, and carry it with you.

Find items and symbols that ground you in the present, not the past. One person uses chocolate.
She loves chocolate and keeps a picture of a Hershey's Kiss with her at all times. She also carries a
Session 10
44

picture of her beloved cat. When she feels she is losing control, she can focus on these very real
images and re-ground herself.

Make a list of things you associate with comfort and safety. Write down times, locations, or people
that help you feel safe. Expand the list as you get new ideas.

Identify and visualize a safe, calm place. Learn to clearly visualize it in your mind. Practice
visualizing over time so when you need to use it to help you feel safe, you will know exactly what to
do.

Imagine a force field around you that no one can penetrate and that shields you from harm. Even the
perpetrator cannot penetrate your safe area. This has been found particularly helpful for survivors
who have trouble feeling safe at night.

Write a statement, saying, or prayer that you find comforting on a piece of paper or card and carry
it with you. Read it when you are stress-free and comfortable in order to reinforce its effect on you.
Then, when you really need it, read it again!

Keep your eyes open and focus on your surroundings. Closing your eyes often increases
dissociation and/or allows sensations to overcome you.

Identify objects in or describe your environment. Be specific and clear. Some people identify a
series of 5 things, counting them on their fingers. Then they identify 4 things, then 3, then 2, then 1.
If you are not re-grounded yet, start backward, 1 to 5. For example, I see a chair (1), the chair is
brown (2), the wall is smooth (3), I see a corner (4), I smell perfume (5).

Place both feet on the ground. Feel the firmness of the ground and your feet against it. Try to focus
on being grounded, stable, and safe.

Produce physical sensations such as rubbing your hands together, holding your forehead and back
of your head between your hands, tapping, or massaging yourself. Wrap yourself in a blanket to feel
contained and safe. If you are prone to self-injurious behavior, be sure to be careful not to do
anything that will hurt you.

Writing in a journal is a good way to begin to put your thoughts together about trauma. Use the
same time of day to write and get into a pattern. Do not be surprised if at first nothing comes forth.
Be patient and try to be consistent. Writing allows experiences, thoughts, and feelings to emerge over
time. Some people use taping with a small recorder first, then writing by hand, or a computer. Use
whatever feels most comfortable and is available. Note that you will probably be writing down very
personal material. Be sure you have a safe place to keep your writing.
Session 10
45

Expressive and Artistic Strategies: Draw, paint, play or listen to music, or write poetry. Find
pictures that are meaningful to you from magazines, newspapers, or posters and put them together in
a pattern to make a collage. You can do collage work about a specific issue, person, or situation. It is
an artistic way to express your feelings and experiences.

Track your triggers. Identify as clearly as possible the situations, people, etc. that cause you to
experience dissociation, body sensations, or self-injury. Identifying what sets you off can help you
learn what to avoid. Some examples of triggers identified by survivors include cold, rough walls,
odors (certain colognes, musty or sexual smells), certain music or other sounds (a ticking clock, a
creaking door), places (certain rooms, buildings) lighting (light/dark), people (appearance or age
similar to the perpetrator).

Identify a safe person with whom you can talk. This person needs to understand enough about your
situation that he or she will be available and will be comfortable with what you want to discuss.
Finding the right person is important. Many people are not safe to use for this purpose. Talk with
this safe person when you are losing control or feel like hurting yourself or others. If you will be
calling the person on the phone, be sure to have the number with you at all times. Keep it in a place
where you can easily find it in an emergency. If possible, have a backup person with whom to speak.
One person may not always be available.

Identify a safe chair where others agree to leave you alone until you regain control. Others should
respect your space and agree to let you do your own work as long as you do not hurt yourself or
others. Using a rocking chair may be helpful.

Strategies to Prevent Self-Injury
Try using a rubber band and snap your wrist with it when you feel the need to self-injure. Brush
yourself with a toothbrush. Hold ice on your wrist or another part of your body.

Injure your favorite stuffed animal or toy before you allow injuring yourself. The injury must be in
the same place and the same depth and length as what you feel you need to do to your own body.
Many people find they are less willing to hurt their toys than themselves. Not hurting a toy keeps
some people from hurting themselves.

Try using a red pen or felt marker on your body instead of cutting. Make the line as long as the
intended cut. If you find you use this line as a mark where you do actually cut, then this approach is
not working. Use another strategy!

Combine strategies when you need to. What works for one person may not work for another.
Remember that, just as your abuse was very individual, your reaction to it is individual, and your
strategies for self-care and safety are also individual. It is important to know in advance what you
Session 10
46

plan to do to center yourself and/or to keep from self-injuring.

You may need to try a variety of strategies before you find one or more that works for you. It is not
important that others use the same strategies; what is important is that your strategies work for you.
Do not become discouraged if a strategy fails. Keep looking for new strategies to help you gain
greater control.

Distribute the Thought for the Day card and briefly discuss its meaning with participants.

Ask members how they felt about today's group
Was it helpful?
Did people feel that their experiences were supported by the group?

Check-out to see if all members are comfortable with their level of personal safety and comfort at this
time.

Group Leader Recommendations

Most group members will have had so much failure in attempting to gain control over their
experiences that they may have given up hope. Thus, participants are likely to deny that anything will
help. Co-leaders should expect to deal with resistance to trying anything at all. Participants must
believe they can change or there is hope for change before they will be able to change.
Participants must select strategies that will work for them. Some of these strategies may sound
strange or irrational, but co-leaders should encourage members to try whatever works as long as no
one is hurt by the approach.
Remind participants that strategies must be practiced and learned during times of calm and control,
not chaos and upset. Practice, practice!
Encourage members to work with individual therapists to complete the selection and integration of
strategies for increased self-control. Group leaders can help between sessions as needed.

Thought for the Day

Learn to control experiences related to your abuse

Materials
Thought of the Day Cards
Session 10 Handout (Coping Strategies for Trauma-Related Experiences and Strategies to
Prevent Self-Injury)
Session 10
47

Session 10 Handout
Coping Strategies for Trauma-Related Experiences

Flashbacks can be very intrusive and disturbing, but you can learn to control their rate and
intensity. Some ideas include:

Carry "safe items" with you. Create a box or bag that contains your safety items and
reminders.
Find symbols that ground you in the present, not in the past.
Make a list of things you associate with comfort and safety.
Identify a place where you feel safe and calm.
Imagine an impenetrable force field around you.
Write down a statement, saying, or prayer that you find comforting.
Keep your eyes open and focus on your surroundings.
Identify objects in or describe your environment.
Place both feet on the ground.
Ground yourself with comforting smells like chocolate, orange, mint, etc.
Produce physical sensations like rubbing your body, holding your head in your hands,
tapping.
Wrap yourself safely in a blanket.
Write a journal, write poetry, draw, paint, collage, create or listen to music
Track your triggers.
Identify a safe person with whom you can talk.
Identify a safe chair where you can be left alone. Try a rocking chair.

Coping Strategies to Prevent Self-Injury

Snap your wrist with a rubber band. Brush yourself with a toothbrush. Hold ice on your
wrist or another part of your body.
Injure your favorite stuffed animal or toy before you allow injuring yourself.
Hit or throw a pillow.
Try using a red pen or felt marker on your body instead of cutting.
Combine strategies when you need to.
Try a variety of strategies until you find what works.
Talk to someone safe about how you are feeling and what they can do to help


Session 11
48

Session 11
Support and Resources: Avoiding Revictimization

Objective

To help group members identify at least one safe resource or support.

Presentation Outline

Check-in with group members to insure that their feelings of personal safety and comfort are
adequate for group work. Identify any special situations or unfinished issues relating to the previous
session that need attention.

Remind group members that there is only one group meeting after today. Discuss contracting for
additional sessions if this option is available.

Use comments of group members to lead into last session's Thought for the Day:
Learn to control experiences related to your abuse.

Any resource listings provided to the group, for example those provided in Session 9, should be
appropriate for the functional levels and severity of psychiatric conditions of group members.
Referral to inappropriate or too-high-level programs may be hurtful or re-traumatizing.

Medical Support
Encourage clients to discuss with their doctors various medications that may be helpful in the
recovery process. There are medications that can help with anxiety, depression, and sleep
disturbances. Members need to remember that it is important that they personally monitor their own
emotional states and keep their doctors and therapists informed of new experiences or changes.

Emotional Support
Primary therapists can be a major source of emotional support. Survivors should be
encouraged to choose therapists who are trustworthy, empathic, and consistent. Survivors
need to arrange for a backup therapist in case the primary therapist is not available.

Group leaders can also be a source of support.

In addition to professional contacts, each group member should try to identify at least one
other person who can be trusted to discuss issues relevant to her abuse history.


Session 11
49

Remind group members that just because someone is a close friend or even a family member
does not mean he/she is necessarily a safe person with whom to talk about abuse. Some
therapists are also less able to discuss trauma than are others. Survivors need to learn whom
they can trust and choose wisely.

Empowerment
Resources and people to whom survivors are referred should embrace a philosophy of empowerment
and encourage survivors to increase control in their lives.

Social Support
In addition to primary therapists, other sources of potential aid might include:
Spiritual or religious community
Support groups
Online resources and support groups
Helpful individuals
Outpatient mental health services

Wellness
It is important to take responsibility to optimize your own health and wellness.
Regular preventive care and treatment for any physical health conditions.
Good sleep hygiene
Learning about proper nutrition and eating habits
Avoiding the use of alcohol and drugs
Regular participation in exercise, relaxation, meditation, yoga, etc.

Distribute the Session 11 Handout and discuss with the group. Remind group members of the rules
for keeping safe that were provided earlier.

Keeping Safe: Some Reminders from Previous Sessions
Choose people you trust with whom to talk about your feelings, trauma, or abuse history. Unhelpful
individuals may include those who are critical and unsupportive with respect to abuse and/or mental
illness, those who pass judgment, those who do not want to hear or know about your history, and/or
those who exploit you sexually, physically, financially, or emotionally.
Avoid dangerous situations, such as walking or driving alone late at night or going to isolated
locations.
It is important to learn to control your memories.
It is essential to learn to "Say No" when needed to stay safe.
Avoid using harmful behaviors such as drugs, alcohol, self-mutilation, or suicide attempts to control
unpleasant feelings.
Learn to recognize and respond appropriately to your personal signs of stress.
Session 11
50

Know your triggers and learn how to avoid them or cope with them safely.
Have clear strategies in place for when you do not feel safe.

Distribute the Thought for the Day card and briefly discuss its meaning with participants.

Note the importance of coming to the last session.

Ask members how they felt about today's group
Was it helpful?
Did people feel that their experiences were supported by the group?

Check-in with individuals to see if all members are comfortable with their level of personal safety
and comfort at this time.

Group Leader Recommendations

A resource list similar to that in Session 9 should be developed for the group. The list should
minimally include mental health services, rape crisis, emergency hospitals, victim services,
and police.

Help group members to identify their own ways to stay safe. Each member should eventually
individualize resource lists to meet her own needs.

Thought for the Day

Safe support groups and individuals are available for help

Materials

Thought of the Day Cards
Session 11 Handout (Keeping Safe)
Session 11
51


Session 11 Handout
Keeping Safe: Some Reminders from Previous Sessions


Choose people you trust with whom to talk about your feelings or your abuse history.

Avoid dangerous situations, such as walking or driving alone late at night or going to isolated
locations.

It is important to learn to control your memories.

It is essential to learn to "Say No" when needed to stay safe.

Avoid using harmful behaviors such as drugs, alcohol, self-harming, or suicide attempts to
control unpleasant feelings.

Learn to recognize and respond appropriately to your personal signs of stress.

Know your triggers and learn how to avoid them.

Have clear strategies in place for when you do not feel safe.

Try out different safe coping strategies to figure out what things work best for you.





52

Session 12
Wrap-Up

Objective

To help participants identify one benefit from the educational trauma group experience.

Presentation Outline

Check-in with group members to insure that their feelings of personal safety and comfort are
adequate for group work.

Use comments of group members to lead into last session's Thought for the Day:
Safe support groups and individuals are available for help.

Ask participants to summarize important issues covered in the series of group meetings. Involve each
group member in this discussion and spend time as appropriate to fully debrief or clarify issues that
are unclear.

Important Issues Discussed in the Group Meetings

Do not blame yourself; you are not to blame for your abuse.
Know how to obtain group and individual therapy for further trauma work.
Know who is safe to talk to.
Know your triggers and learn how to control them.
Identify safe people.
Know who is available, and when, and have their phone numbers written down.
Take good care of yourself physically, emotionally, and spiritually.
Learn what hurts and do not allow anyone to hurt you.
Recognize and avoid dangerous situations.
Learn coping methods that work for you and do not hurt you.
Know where you can obtain support services.

Discuss issues relating to termination:

Feelings about leaving the group and its members
Feelings about having a second series of groups dealing with additional educational material related
to abuse
Topics group members would like covered in a second series of groups
Respond to questions or unfinished business raised by group members.
Have group members complete feedback evaluation forms.
Ensure members have adequate therapeutic and support systems in place after group sessions end.

53


Distribute the Thought for the Day card and briefly discuss its meaning with participants.

Ask members how they felt about todays group
Was it helpful?
Did people feel that their experiences were supported by the group?

Check-in with individuals to see if all members are comfortable with their level of personal safety
and comfort at this time.

Group Leader Recommendations

Since this is the final group session, this is not the time for members to introduce new material, make
intense personal disclosures, or open up controversial issues.

If it seems appropriate to group leaders and if practical, this final session could be a celebration to
mark the beginning of recovery from the effects of childhood trauma.

The decision should have already been made regarding re-contracting for additional sessions, with
potential participants identified.

Appropriate food and drinks are often appreciated by group members in this final session.

Thought for the Day

Take good care of yourself and don't allow anyone to hurt you


Materials

Thought for the Day Cards
Session 12 Handout (Important Issues Discussed in the Group Meetings)
Group Participant Evaluation Form

54

Session 12 Handout
Important Issues Discussed in the Group Meetings


Do not blame yourself; you are not to blame for your trauma or abuse.

Know where you can obtain support services.

Know how to obtain group and individual therapy for further trauma work.

Know who you can talk to or who it is not safe to talk to.

Know your triggers and learn how to control them.

Identify safe people and supports.

Know who is available, and when, and have their phone numbers written down.

Take good care of yourself physically, emotionally, and spiritually.

Learn what hurts and do not allow anyone to hurt you.

Recognize and avoid dangerous situations.

Learn coping methods that work for you and do not hurt you.

55





APPENDICES

Appendix A: Group Evaluation Form
56

Group Evaluation Form

Circle the answer that most clearly describes your opinion.

1. The size of this group was: (a) Too small (b) J ust right (c) Too big

2. The length of the sessions was: (a) Too short (b) J ust right (c) Too long

3. The group discussion part of each group was: (a) Not helpful (b) Helpful (c) Very helpful

4. The lecture part of each group was: (a) Not helpful (b) Helpful (c) Very helpful

5. The Thoughts for the Day were: (a) Not helpful (b) Helpful (c) Very helpful

6. The co-leaders were: (a) Not helpful (b) Helpful (c) Very helpful

7. Circle the topics you liked the best:
(1) Safety (4) Coping with abuse
(2) What is abuse? (5) Talking about abuse
(3) Effects of abuse (6) Ways to get help

8. Circle the topics you liked the least:
(1) Safety (4) Coping with abuse
(2) What is abuse? (5) Talking about abuse
(3) Effects of abuse (6) Ways to get help

9. The video used during the group was: (a) Not helpful (b) Helpful (c) Very helpful

10. Did this group give you all the information you wanted? Circle your answer: Yes No

11. What topics do you think should be included in the future?

12. Would you recommend a group like this for other men? Circle your answer: Yes No

13. Do you think this group should be continued? Circle your answer: Yes No

14. Did this group help you in any way? Circle your answer: Yes No

15. If so, how did this group help you?

16. Is there anything else you would like to tell the co-leaders about this group?


Appendix A: Group Screening Form 1/2
57

Group Screening Form

Name:

Age:
ID number:

Primary Therapist: Phone:
Psychiatrist: Phone:
Reason for referral:

Motivation to be a part of the group:
Proficiency in spoken English:
Family history (including substance abuse):



Family or other support:
Current living situation:
Trauma/abuse history: (see ACE)
Past and current treatment for sex abuse:


Disclosure of abuse history (to whom, when, and how experienced):
Does patient discuss abuse history with therapist?
Psychiatric diagnosis:
Current symptoms:










Appendix A: Group Screening Form 2/2

58
Group Screening Form

Name:

Medication (s):
Medical history:
Psychiatric hospitalizations:
ID number:


Suicidal, assaultive, or self-harm behavior:
Defensive/coping styles:
Substance abuse history:
Behavioral profile (school problems, runaway etc.)
Group Related Issues:
Ability to make contract for attendance for duration of group (12 weeks):


Level of understanding of group guidelines/rules:


Overall impression of ability to benefit from an Educational Group for Trauma & Abuse (strengths,
weaknesses, concerns, etc.).




Recommend for group: Yes No
Notat this time

Signature: Date:
Diagnostic Resources of Potential Interest:
Title:
Trauma Symptom Checklist Brief Psychotic Rating Scale
Dissociation Checklist Scales of Psychoticism
Depression Belief Inventory (J ehu) Beck Depression Inventory
Rosenberg Self-Esteem Scale Hamilton Depression Scale
Stigma Scale CESD (Scale of Depression)
Adverse Childhood Experiences scale PTSD section of SCID (Structured
Clinical Interview for Diagnosis)




Appendix A: ACE Score
59
While you were growing up during your first 18 years of life:

1. Were your parents ever separated or divorced? Yes No

2. Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her?
Or
Sometimes, often or very often kicked, bitten, hit with a fist, or hit with something hard?
Or
Ever repeatedly hit at least a few minutes or threatened with a knife or a gun? Yes No


3. Did you live with anyone who was a problem drinker or alcoholic or used street drugs? Yes No

4. Did a household member go to prison? Yes No

5. Was a household member depressed or mentally ill, or did a household member attempt suicide?
Yes No

6. Did you often or very often feel that
You didnt have enough to eat, had to wear dirty clothes, and had no one to protect you?
Or
Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Yes No

7. Did you often or very often feel that
No one in your family loved you or thought you were important or special?
Or
Your family didnt look out for each other, feel close to each other, or support each other?
Yes No

8. Did a parent or other adult in the household often or very often
Swear at you, insult you, put you down, or humiliate you?
Or
Act in a way that mad you afraid that you might be physically hurt? Yes No

9. Did a parent or other adult in the household often or very often
Push, grab, slap, or throw something at you?
Or
Ever hit you so hard that you had marks or were injured? Yes No

10. Did an adult or person at least 5 years older than you ever
Touch or fondle you or have you touch their body in a sexual way?
Or
Attempt or actually have oral, anal, or vaginal intercourse with you? Yes No


Appendix A: Pre-Group Questionnaire
60
Trauma Pre-Group Questionnaire


Name: ID number:

Answer each question as True (T) or False (F):

1. Forgetting is a way of coping with the trauma and abuse.

2. Sexual abuse is always a trauma for the child.

3. If someone is abused, it is best not to talk about it.

4. Adult survivors of abuse often feel that they deserved it.

5. It is never possible to recover from severe childhood abuse.

6. Children who are abused never have problems concentrating in school.

7. If a child has been abused, family members can help by keeping it a secret.

8. Memories of trauma and abuse can come in the form of dreams and body sensations.

9. All therapists understand trauma and abuse and are good people to talk to about it.

10. Alcoholism and drug abuse are never effects of abuse.

11. People who are abused as children always remember it.

12. Shame keeps people from talking about trauma or abuse.

13. Adult survivors of abuse often have trouble managing anger and other feelings.

14. Avoiding situations that trigger flashbacks is a good way of controlling them.

15. Trauma and abuse of children is very rare.

16. Flashbacks are never memories of trauma or abuse.

17. Forced sexual intercourse is the only kind of sexual abuse.

18. If a child is abused by an adult, the child is to blame.

19. Talking about trauma and abuse is important in recovery.

20. People who have been abused have difficulty trusting others.

21. People who have had trauma or abuse during childhood have more health problems as adults.

___ 22. Boys and men rarely experience trauma and abuse during childhood or adulthood.
Appendix B: Thoughts for the Day 1/2
61








Session 1
Thought for the Day
Session 2
Thought for the Day


Learning about trauma and
abuse is a step toward healing
You deserve to feel and be
safe!











Session 3
Thought for the Day


Trauma and abuse
are very common
Session 4
Thought for the Day


Talking about trauma and
abuse can lead to healing











Session 5
Thought for the Day


It is important to know
whom you can trust
Session 6
Thought for the Day


The child is not responsible
for the abuse
Appendix B: Thoughts for the Day 2/2
62







Session 7
Thought for the Day
Session 8
Thought for the Day


Trauma and abuse can
lead to emotional and
physical difficulties
People have individual reactions
to childhood trauma









Session 9
Thought for the Day


Strategies needed by
a child may not be
useful to an adult
Session 10
Thought for the Day


Learn to control experiences
related to your trauma and
abuse






Session 11
Thought for the Day


Safe support groups and
individuals are available
for help
Session 12
Thought for the Day


Take good care of yourself
and don't allow anyone to
hurt you

Appendix C: Suggested Readings
63
In addition to the References listed at the end of the Introduction, the authors suggest the
following reading list:

Adverse childhood experiences study and repository of research findings. See online:
http://www.acestudy.org and http://www.cdc.gov/ace/ [last accessed 03/14/2014]

Bass, E., & Davis, L. (1988). The courage to heal: A guide for women survivors of child
sexual abuse. New York: Harper and Row.

Braun, B. G. (1989). Psychotherapy of the survivor of incest with a dissociative disorder.
Psychiatric Clinics of North America, 12(2):307-324.

Cohn, B. R. (1988). Keeping the group alive: Dealing with resistance in a long-term group
of psychotic patients. International J ournal of Group Psychotherapy,
38(3):319-335.

Cole, C. H., & Barney, E. E. (1987). Safeguards and the therapeutic window: A group
treatment strategy for adult incest survivors. American J ournal of Orthopsychiatry,
57(4):601-609.

Colson, D. B. (1985). Transference-counter transference patterns in psychoanalytic group
therapy: A family systems view. International J ournal of Group Psychotherapy,
35(4):503-518.

Coons, P. M., Bowman, E. S., Pellow, T. A., & Schneider, P. (1989). Post-traumatic aspects of
the treatment of victims of sexual abuse and incest. Psychiatric Clinics of North America,
12(2):325-335.

Cornell, W. F., & Olio, K. A. (1991). Integrating affect in treatment with adult survivors
of physical and sexual abuse. American J ournal of Orthopsychiatry, 59-69.

Courtois, C. A. (1991). Theory, sequencing, and strategy in treating adult survivors. New Directions
in Mental Health Services, 51:47-60.

Courtois, C. A. (1992). The memory retrieval process in incest survivor therapy. J ournal of Child
Sexual Abuse, 1:15-31.

Courtois, C., & Watts, D. L. (1982). Counseling adult women who experienced incest in childhood
or adolescence. Personnel and Guidance J ournal, 60:275-279.

Appendix C: Suggested Readings
64
Den Herder, D., & Redner, L. (1991). The treatment of childhood sexual trauma in chronically
mentally ill adults. Health and Social Work, 16(1):50-57.

Dimok, P. T. (1988). Adult males sexually abused as children. J ournal of Interpersonal
Violence, 3:203-221.

Draucker, C. B. (1992). The healing process of female adult incest survivors: Constructing a
personal residence. J ournal of Nursing Scholarship, 24(1):4-8.

Ellenson, G. S. (1989). Horror, rage, and defenses in the symptoms of female sexual abuse
survivors. J ournal of Contemporary Social Work, 589-595.

Faria, G., & Belohlavek, N. (1984). Treating female adult survivors of childhood incest. Social
Casework, 465-471. (October, 1984)

Ganzarain, R., & Buchele, B. (1986). Counter transference when incest is the problem. International
J ournal of Group Psychotherapy, 36(4):549-566.

Goodman, B., & Nowak-Scibelli, D. (1985). Group treatment for women incestuously abuse as
children. International J ournal of Group Psychotherapy, 35(4):531-544.

Goodwin, J . M., & Talwar, N. (1989). Group psychotherapy for victims of incest. Psychiatric
Clinics of North America, 12(2):279-293.

Gordy, P. L. (1983). Group work that supports adult victims of childhood incest. J ournal of
Contemporary Social Work, 300-307. (May, 1983)

Herman, J . L., & Schatzow, E. (1987). Recovery and verification of memories of childhood sexual
trauma. Psychoanalytic Psychology, 4(1):1-14.

Kilgore, L. C. (1988). Effect of early childhood sexual abuse on self and ego development. J ournal
of Contemporary Social Work, 224-230.

Knittle, B. J ., & Tuana, S. J . (1980). Group therapy as primary treatment for adolescent victims of
intrafamilial sexual abuse. Clinical Social Work J ournal, 18(4):236-242.


Lew, M. (1988). Victims no longer: Men recovering from incest and other sexual child abuse. New
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Appendix C: Suggested Readings
65

Lyon, E. (1993). Hospital staff reactions to accounts by survivors of childhood abuse. American
J ournal of Orthopsychiatry, 63(3):410-416.

McWilliams, N., & Stein, J . (1987). Women's groups led by women: The management of devaluing
transferences. International J ournal of Group Psychotherapy,
32(2):139-153.

Mennen, F. E. (1990). Dilemmas and demands: Working with adult survivors of sexual abuse.
Affilia, 5(4):72-86.

Patten, S. B., Gatz, Y. K., & Thomas, D. L. (1989). Posttraumatic stress disorder and the treatment
of sexual abuse. Social Work, 197-203.

Rieker, P. P., & Carmen, E. (1986). The victim-to-patient process: The disconfirm ation and
transformation of abuse. American J ournal of Orthopsychiatry, 56(3):360-370.

Rosenthal, K. (1988). The inanimate self in adult victims of child abuse and neglect.
J ournal of Contemporary Social Work, 505-510.

Roth, S., & Batson, R. (1993). The creative balance: The therapeutic relationship and thematic
issues in trauma resolution. J ournal of Traumatic Stress, 6(2):159-177.

Roth, S., & Newman, E., (1990). The process of coping with sexual trauma. J ournal of
Traumatic Stress, 4(2):279-297.

Stone, M. H. (1989). Individual psychotherapy with victims of incest. Psychiatric
Clinics of North America, 12(2):237-255.

Summit, R. C. (1989). The centrality of victimization: Regaining the focal point of recovery for
survivors of child sexual abuse. Psychiatric Clinics of North America,
12(2): 413-430.

Talmadge, L. D., & Wallage, S. C. (1991). Reclaiming sexuality in female incest survivors. J ournal
of Sex and Marital Therapy, 17(3):163-182.

van der Kolk, B. (1989). The compulsion to repeat trauma. Psychiatric Clinics of North
America, 12(2):389-411.


Appendix C: Suggested Readings
66
Wayne, J ., & Weeks, K. K. (1984). Groupwork with abused adolescent girls: A special challenge.
Social Work with Groups, 7:83-104.

Wylie, M. S. (1993). The shadow of a doubt, Networker, 18-45. (September/October,
1993)

Yassen, J , & Glass, L. (1984). Sexual assault survivors groups: A feminist practice perspective.
Social Work, 252-257.